Summary

The Provider Enrollment Specialist follows procedures for enrolling providers with managed care plans and maintains the Council of Affordable Quality Healthcare (CAQH) applications. Maintains high level of teamwork, customer service and consistency. Assures procedures are followed with attention to detail.

 

Essential Duties and Responsibilities

The duties and responsibilities described below represent the general tasks performed daily.  Other duties may be necessary to drive to help fulfill the mission and abide by the values of the organization.

 

Compiles, audits and expedites processing of all information in the CAQH database and confidential credentials files. Facilitates credentialing functions and application management with health plans and/or medical staff services. Consistently updates credentialing databases and designated spreadsheets with demographic information and constructs various related reports.

 

Collects provider identification (NPI) login numbers and passwords for all new providers at on-boarding, Revises National Plan & Provider Enumeration System (NPPES) database for new providers. Maintains spreadsheet and/or MD Staff database with appropriate information and follows up with providers for any additional information needed.

 

Disseminates demographic provider and practice location changes to Medical Staff Services, IT, and HR for each change and communicates all changes to the health plans based on department policy and procedure.

 

Prepares, submits, and tracks payer enrollment and credentialing material submissions. Identifies variances, issues, and delays, addressing them in a timely manner; escalating with internal and external stakeholders and management as needed.

 

Performs ongoing outreach and follow-up with providers, payers, and vendors, ensuring that contractual obligations (turnaround timeframes, credentialing and loading requirements) are met, and escalating when deficiencies are identified.

 

Audits materials returned by providers, payers, and vendors for accuracy and completeness, addressing variances in a standardized way according to well-defined standard operating procedures.

 

Prepares and distributes status updates to stakeholders for accurate and timely updating of internal and external platforms (including but not limited to databases, credentialing grids, dictionaries, portals, and websites).

 

Serves as a key contributor to special credentialing, enrollment, and operational projects, including large-scale initiatives and additional services and functions.

 

Performs compliance checks and quality assurance activities to maintain the integrity of data and ensure adherence to standard operating procedures.

 

Complies with Federal, State, Center for Medicare & Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and the DNV standards throughout the enrollment and credentialing process.

 

Serves as the primary point of contact for providers, payers, and vendors. Leads regular meetings to discuss the status of open items and deliverables, preparing agenda in advance, and following up with meeting minutes. Escalates to internal and external stakeholders as needed.

 

Performs scheduled and ad-hoc audits of payer data ensuring updates are made in credentialing and provider enrollment database and discrepancies are addressed with external parties.

 

Administers credentialing and enrollment processes in accordance with NCQA guidelines, including quality assurance and compliance tasks, delegated credentialing payer audits/reporting, and coordination of Medical Group Credentialing Committee processes.

 

Establish and maintain positive relationships with payers, providers, practices, and administration, providing subject matter expertise and tailoring communications to adapt to each audience.

 

Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest developments to enhance understanding of various regulations and legislation of the health care industry.

 

Maintains proficiency in credentialing and enrollment databases and their functionality, and other reporting tools to validate data from multiple sources.

 

Works collaboratively with fellow team members to regularly evaluate the effectiveness of department Standard Operating Procedures and workflows and identify gaps. Provides feedback and recommendations to supervisor for improvements. Implements approved changes.

 

Performs other related duties as assigned within the scope of job.

 

Maintain familiarity and stay current with NCQA and all applicable regulatory requirement, health insurance plan policies, medical group credentialing and enrollment policies, and other related policies necessary for credentialing and enrollment of providers.

 

Maintain knowledge of relevant State, Federal and regulatory requirements.

 

Participates in committees, task forces, and workgroups as assigned.

 

Conforms to all applicable HIPAA, Billing Compliance, and safety policies and guidelines.

 

Maintain the highest level of confidentiality regarding practitioner personal information and related peer review information.

 

Other: Attend required hospital-wide orientations, meetings, patient safety fairs, in-services, as well as job-related conferences, audio conferences and webinars. Demonstrate a commitment to flexible work scheduling when necessary to ensure adequate departmental staffing and efficient department operations. Improve professional growth and job performance by participation in professional organizations such as Tidewater Association Medical Staff Services (TAMSS) and Virginia Association Medical Staff Services (VAMSS) and by reading pertinent journals and publications addressing current Medical Staff issues.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education: Associate degree or higher

Preferred Education: Bachelor’s degree or higher

Experience: A minimum of 3 years of related experience in provider enrollment to include experience with an electronic credentialing database application

Certificates, Licenses, Registrations

Preferred certifications:  National Association Medical Staff Services CPCS or CPMSM

Certifications or achieve certification within 2 years of hire.