Sr. Provider Enrollment Specialist - Managed Care

EDUCATION & EXPERIENCE:

Minimum Qualifications:

• Three years of experience in healthcare, insurance, business, or managed care, with at least one year involving provider enrollment, billing, or related administrative support.
• An equivalent combination of education and experience relevant to the role may be considered for this position.

Preferred Qualifications:

• Associate’s degree in business, healthcare administration, public administration, or related field.
• Four years of experience in healthcare, insurance, business, or managed care, with at least one year involving provider enrollment, billing, or related administrative support.

JOB SUMMARY:

The Provider Enrollment Specialist, Sr. supports the provider enrollment process by performing administrative and clerical tasks under general supervision. This role assists with the coordination of provider enrollment, re-enrollment, and updates for medical staff and allied health practitioners. Responsibilities include preparing and submitting enrollment applications, tracking statuses, and maintaining accurate records. The specialist communicates with internal departments and external agencies to ensure required information is obtained and processed in a timely manner. This position works closely with the Provider Enrollment Manager and other team members to support accurate and timely enrollment, helping to minimize delays and support effective billing and reimbursement processes.

ESSENTIAL JOB FUNCTIONS:

• Identifies areas for improvement and assists in implementation of new/revised processes.
• Monitors status of incoming requests and provider enrollment activities to ensure all issues/requests/activities are addressed in a timely manner and within deadlines.
• Develop processes and instructions and conducts training as needed.
• Obtain licensure, certification and insurance certificates at time of enrollment and maintain in database in order to submit with enrollment applications.
• Maintain timelines on enrollment processes, and address and/or escalate any delays.
• Ensure that all pending enrollments are reviewed, obtained and managed according to the rules and policies of the department.
• Provide monthly notification of new providers, resignations, and changes in provider status such as practice locations and panel status to contracted plans.
• Follow up with necessary contacts, including providers and managed care organizations, to resolve enrollment application issues and deficiencies.
• Facilitate resolution of provider related denials to ensure appeal procedures are followed to result in proper reimbursement.
• Respond to internal and external inquiries on routine enrollment and contract matters, as appropriate.
• Perform detailed follow-up activities on assigned accounts according to procedures.
• Assists in resolving outstanding AR accounts due to Provider Enrollment denials.
• Maintain confidentiality of all provider enrollment business/work and medical staff information.  

Marginal or Periodic Functions:

• Participates in projects and other tasks assigned by leadership.
• Participate in team meetings/activities and support the philosophy and goals of the team and department.
• Read all announcements and relevant communications relating to job duties.
• Successfully complete competency-based training and testing.
• Adheres to internal controls and reporting structure.
• Performs related duties as required.

KNOWLEDGE/SKILLS/ABILITIES:

• Knowledge of insurance claim processing and third-party reimbursement.
• Knowledge of CMS regulatory requirements.
• Effective oral, written, and interpersonal communication with the ability to relay confidential information appropriately.
• Skill in time management and project management.
• High level of attention to detail with exceptional organizational skills.
• Ability to function independently.
• Ability to work and lead a team environment.
• Advanced Microsoft platform skills.
• Demonstrated skills in problem solving, analysis and resolution.
• Must comply with HIPAA rules and regulations.

WORKING ENVIRONMENT/EQUIPMENT:

• Standard in-office environment.
• Standard office equipment.

SALARY RANGE:

Actual salary commensurate with experience.

WORK SCHEDULE:

On-site, Monday - Friday, 8 am - 5 pm.