The Provider Credentialing/Enrollment Specialist the primary responsibility is to manage all credentialing/payer enrollment for new and existing providers with all payers. Work closely with HR for new provider onboarding, submit enrollment applications to insurance companies accurately and timely and track progress of each provider and payer to ensure established timeframes are met, meeting the needs of the organization such as following up on the status of applications for clinicians and payers and track the progress on all pending applications, as well as responsible for the management and utilization of credentialing software allowing for automation and tracking. Individual must have knowledge of the various government and private payer credentialing and enrollment guidelines, steps and processes. In this role, the individual will also be responsible for vendor enrollment for ERA/EFT.
ESSENTIAL FUNCTIONS AND BASIC DUTIES
- Collect and manage all credentialing documents for providers regarding payer enrollment new and established.
- Submit enrollment applications to insurance companies and follow-up until enrollment is completed
- Complete re-credentialing for established providers as required by payers
- Knowledge and experience in insurance credentialing and re-credentialing for PPO, HMO, Medicare and Medicaid payers
- Register and Maintain providers with CAQH and PECOS, managing organization linkage, maintaining attestation.
- Responsible for coordination with HR for new provider onboarding and completion of provider enrollment
- Interact with Doctors and HR to gather and maintain updated credentialing documents for all clinicians
- Responsible for tracking clinical facility licensure and ensuring compliance
- Keep up to date provider enrollment processes and track provider participation levels
- Enter and maintain all Provider information in the credentialing database, tracking of submissions and effective statuses; Provide regular updates to organization on credentialing status of doctors
- Maintain databases of updated credentialing forms and doctor information
- Maintain updated directory of fee schedules and ensure their accuracy in PMS
- Follow-up with provider relations to accelerate credentialing process time frame and develop relationships with insurances
- Maintain insurance provider directories/roster for accuracy
· Aides the Revenue Cycle Department in the resolution of complex or advanced issues related to provider enrollment with payers claim denials
- Maintain Payer website logins and passwords for organization
- Improve processes to streamline and optimize credentialing process utilizing Third party application to manage and maintain documentation.
- Meet required turnaround times and accuracy rates
- Performs other duties as necessary or assigned
- Conducts job duties in accordance with the Corporate Values and Culture - Others First - Others before self - Wisdom - Do the wise thing - Growth - Keep getting better
QUALIFICATIONS – EDUCATION, WORK EXPERIENCE, CERTIFICATIONS
- 3+ years of experience in provider enrollment
KNOWLEDGE, SKILLS, AND ABILITIES
- Knowledge of medical insurance carrier policies and procedures, State and Federal rules and regulations
- Medicare, Medicaid, and Commercial Payer Provider Enrollment knowledge
- Knowledge of CAQH and PECOS
- Working knowledge for CMD Skills/abilities
- Strong organizational, planning, and decision-making skills
- Ability to adapt to a changing environment
- Strong written and verbal communication skills
- Ability to work effectively in a fast-paced environment
- Proficiency in Microsoft Office, particularly Excel and Word
- Professional written and verbal communication and interpersonal skills require
- Ability to effectively communicate with team members, supervisors, client staff and insurance contacts
- Ability to maintain complete confidentiality in handling sensitive enrollment issues
Job Type: Full-time
Pay: $50,000.00 - $75,000.00 per year
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
Work Location: Hybrid remote in Richmond Hill, GA 31324