Provider Enrollment Specialist

The Provider Enrollment Specialist reports to the Director of Managed Care Contracting and Enrollment and is responsible for all aspects of the enrollment and enrollment re-validation processes for all billable medical providers who provide patient care on behalf of Phelps Health.

Essential Duties & Responsibilities:

1. Responsible for ensuring the timely enrollment of new providers and facility sites and the on-going maintenance of existing providers and facility sites with payors. This would include re-validations and maintaining terminations. Notify payors and internal contacts of practitioner practice changes, including terminations. Also, will notify payors of site notification for payors (i.e., for new sites, site terminations, and changes).

2. Initiate and complete enrollment for electronic claims submission.

3. Apply for or provide assistance with the application process for individual practitioner and/or facility national provider identifier (NPI) via national plan and provider enumeration system (NPPES). As well as, assistance with completed all Provider Enrollment related applications.

4. Monitor and maintain the process of gathering current, accurate, and complete information for provider directories and payor databases in compliance with regulations and payor requirements. These may include, but are not limited to, supporting documentation such as a W-9, CLIA certificate, bank, IRS and CMS letters as applicable.

5. Follow up with payors to obtain effective dates, status updates, and identification numbers for billing purposes. Update and maintain provider numbers and related data in both internal and external billing software and production programs.

6. Perform account follow up on enrollment related denials and take the necessary action for account resolution in accordance with established federal and state regulations. Respond to internal and external inquiries regarding research issues. Review charges and claims pending report and/or claim edit work queues in EHR/EMR. May work EHR/EMR follow-up work queues to resolve enrollment-related issues.

7. Complete work within a timely manner to assure compliance with departmental and compliance standards as well as payor time limits. Complete all “add-on” projects as assigned by Director.

Education

High School diploma or equivalent required. Associates degree in Accounting, Business, Healthcare Administration preferred.

Work Experience

Two to three years of experience in medical business office environment required.

Extensive knowledge of Microsoft Word, Excel, and Outlook.

Excellent verbal and written communication skills required.

Self-motivated, independent worker with strong time management skills and attention to detail required.

Previous provider enrollment, credentialing or insurance billing experience preferred.

Certification/License

None required.