Provider Enrollment Specialist

Pinnacle Wound Management is looking for an experienced Healthcare credentialing coordinator/provider Enrollment to join our team.

Pinnacle Wound Management and its national network of affiliated wound care specialist provide weekly wound care to nursing home residents.

Job Summary: The Healthcare Credentialing Specialist will assist in maintaining active status for all providers and facilities by successfully completing initial and subsequent credentialing packages as required by the state. This will include maintaining individual provider and facility s updated profiles in various health insurance portals, CAQH, PECOS, NPPES, Navinet, Availity, PlaySpan, CMS databases, commercial plans, and Managed Care Organizations portals. Assist new individual provider completing application for National Provider Identifier (NPI), Medicare #, and Medicaid #.

Duties And Responsibilities:

• Maintain individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications.
• Maintain contracted Managed Care Organizations, commercial payers, CMS Medicare, Medicaid, PECOS, NPPES, and CAQH tracking log to ensure all necessary portals logins are active and available.
• Work with individual providers to ensure each provider s CAQH database files are updated timely according to the schedule published by CMS Medicare/ Medicaid and Managed Care Organizations regulations.
• Assist new individual provider completing application for National Provider Identifier (NPI) and/or Medicare and Medicaid provider numbers.
• Terminating enrollment with government and commercial payers upon resignation or termination of providers
• As directed, provide updated demographic information with supporting documents to outside participants, such as commercial managed care plans and contracted billing entities.
• Work closely with the Director of Operations to ensure all individual providers are credentialed and recredentialed timely.
• Maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases.
• Responsible of ensuring provider collected information is current and accurate.
• Responsible of coordinating, monitoring, and maintaining the credentialing and re-credentialing process, re-credentialing, and contracting processes with insurance companies.
• Insuring interpretation and compliance with the appropriate accrediting and regulatory agencies.
• Contacting Managed Care Organizations, Commercial plans, CMS Medicare, and Medicaid and/or other insurance agencies to follow up on several stages in credentialing.
• Identifies potential onboarding issues or concerns; research, provides clarification, and facilitates problem resolution.
• Responsible of collaborating and advising as appropriate to limit company legal liability and escalates non-compliance issues and concerns.
• Identifies trends and issues with the onboarding process flow; makes improvement recommendations to department director.
• Keep track of the expiration date for the state DEA license, Board certification, and Malpractice insurance of individual providers.
• Other tasks as needed to support the Revenue Cycle Management Department and BAC.

Knowledge, Skills, And Abilities:

• Excellent interpersonal communication skills and the ability to empathize with others.
• Possesses excellent judgment and the ability to maintain professional relationships and boundaries when working with internal and external colleagues and organizations.
• Minimum Intermediate computer proficiency in Microsoft office programs, internet, email and EHR systems.
• Strong verbal and written communication skills
• Behavioral health knowledge is a plus.

Education:

• Minimum: High School Diploma or equivalent and 5 years experience in healthcare administration, credentialing individual providers and facilities.
• Associate and minimum 2 years experience in healthcare administration, credentialing individual providers and facilities preferred.

Work Experiences:

• Minimum: Two (2) year experience in healthcare credentialing and enrolling individual providers through PECOS, NPPES, CAQH, Managed Care Organization, commercial plans, and various clearinghouse s portals like Navinet and Availity.
• Two (2) years experience tracking license and certification expirations for all providers
• Two (2) years direct credentialing and provider enrollment experience (required)

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Free parking
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday
• No nights
• No weekends

Application Question(s):

• Do you have experience using CAQH?
• Do you have experience using PECOS?
• Do you have experience enrolling providers with different state Medicare Contractors?

Experience:

• provider enrollment and health care: 2 years (Required)
• EDI and ERA set up: 2 years (Required)

Ability to Relocate:

• Buford, GA: Relocate before starting work (Required)

Work Location: In person