Provider Enrollment Specialist I

We are recruiting for a motivated Provider Enrollment Specialist I to join our team!

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Department

Medical Staff Services and Provider Enrollment

Job Summary

Under minimal supervision coordinates, monitors and maintains Medicare, Medicaid and Dental Plans enrollments for the Medical Staff and Advanced Practice Providers. Ensures compliance with the accrediting and regulatory agencies (i.e., TJC, NCQA, and CMS) in regards to credentialing while developing and maintaining a working knowledge of the statues and laws.

Essential Functions:

• Coordinates and facilitates the enrollment of professional providers with various payers for professional services and governmental reimbursement through, Medicare and Medicaid. (45%)
• Reviews provider credentialing and/or recredentialling/revalidation data for accuracy based on licensing requirements and various insurer and government payer requirements. Obtains information from professional providers and other resources. (10%)
• Completes timely application processes based on payer and government specific formats. Continually follows up on enrollment and/or recredentialling/revalidations statuses until complete (5%)
• Maintains systems/applications used in the enrollment processes. (5%)
• Completes provider payer enrollment/credentialling and recredentialing with all identified payers in a timely manner. Handles highly sensitive and confidential information regarding professional providers (5%)
• Resolves enrollment issues through collaboration with physicians, non-physicians, office staff, management, contracting, insurers, and others as identified. Maintains positive working relationships with providers. Plays an active role in explaining and informing providers and practice/office managers of the submission requirements for credentialing/recredentialing processes, stressing the importance of compliance with these processes. (5%)
• Obtains updated provider information from various sources including provider offices, state licensing boards, malpractice insurance companies, residency training programs, etc. Identified and resolved problems with primary source verification elements by interpreting, analyzing, and researching data (5%)
• Proactively obtains updated provider credentialing data prior to expiration. Creates, develops, and maintains applicable matrices and/or utilizes departmental software that supports the enrollment functions. Completes all additions, updates, and deletions. Supports new provider onboarding processes related to enrollment (5%)
• Provides updates to on-site practice management staff and others with any changes to requirements for credentialing individual providers based on government and commercial payer credentialing processes. Proactively communicated any changes regarding contracting as it relates to enrollment and operations (5%)
• Communicates updated payer enrollment information including payer provider numbers to practice operations in a timely manner while fostering working relationships and team work with departments, vendors, etc. (5%)
• Develops databases and spreadsheets for tracking organization providers. Ensures data is accessible/transparent for executive inquiries or other information as deemed necessary by management. (5%)

Education:

• High School Diploma or GED High School Diploma or equivalent required Required and
• PESC Certification Required

Work Experience:

• 4-6 years Five years experience in credentialing and enrollments with Payors, Medicare, Medicaid and Dental Payors Required

Licenses:

Knowledge, Skills and Abilities:

• Knowledge of federal and Colorado statutes, legislative initiatives and regulations, as well as federal, State and local policies.
• Knowledge of TJC, NCQA and/or CMS credentialing standards
• Proficient in Microsoft Word, Excel, and Outlook.
• Ability to simultaneously coordinate and manage several functions, programs, and tasks in various stages of completion
• Ability to interpret and apply policies and procedures
• Skilled in providing excellent customer service.
• Ability to communicate in a professional and positive manner
• Ability to consistently implement program, department and organizational policies and procedures.
• Must be able to work independently and