Managed Care Specialist-Intermediate

Job Summary:

Under general supervision, assist in the provider enrollment process for credentialed provider. Responsible for preparing and submitting provider enrollment applications and supporting documentation to enroll credentialed providers with Medicare and Medicaid. Prepare reports of provider data necessary for distribution to all payors and internal departments. Responsible for providing renewal licensure and certifications to Medicare and Medicaid. Prepare and submit Medicare and Medicaid revalidations and reenrollment. Work closely with internal department on provider enrollment matters. Responsible for monitoring and maintaining up-to-date data for each credentialed providers in the provider enrollment database. Utilize the Proview/CAQH, NPPES, PECOS and TMHP database for enrollment process.

Job Duties:

1. Utilize knowledge & skills set to accurately complete Medicare, Tricare, and Medicaid Programs provider enrollment application.

2. Follow up with necessary contacts, including providers and managed care plans, to resolve enrollment application issues.

3. Completes provider enrollment applications through databases (i.e., CAQH, NPPES, PECOS and TMHP database)

4. Provide documentation and prepare reports of provider data necessary for distribution to all payors, including Medicare Advantage and Managed Medicaid.

5. Enters provider credentialing information into enrollment databases and ensures that the data is current and accurate.

6. Ensures the enrollment packets received from credentialing coordinators are appropriately signed, complete and accurate, with necessary attachments.

7. Prepare reports to provide the payors of changes in billable provider demographics, practice locations, name changes, etc.

8. Performs all other duties as assigned.

KSA’s:

•  Demonstrate strong interpersonal skills & excellent communication skills both written & verbal.

•  Strong organizational skills, detail-orientation with the ability to prioritize and meet deadlines on an ongoing basis to ensure timely completion according to process requirements

•  Strong organizational, critical thinking and problem-solving skills.

•  Knowledge of Word Processing software, database software, spreadsheet, and Internet software

Education:

Associates Degree required. Experience may be in lieu of education. 

Experience:

2 years of progressively responsible experience in a business office or managed care credentialing setting with specific experience in provider enrollment.