Provider Enrollment Specialist
**THIS IS A TEMPORARY ROLE with an anticipated length of 30 +/- days.
The Provider Enrollment Specialist directly impacts the financial stability of the Company by representing SCP Health in the provider number approval process. The Provider Enrollment Specialist, using his/her knowledge of SCP Health policies in conjunction with insurance carrier credentialing and enrollment requirements, facilitates provider enrollment and billing privileges. This position is responsible the coordination of insurance plan enrollment and credentialing activities among various parties, including the Provider, Regional Operations staff, Insurance Carrier and Billing Company Representatives.
- Process Medicare, Medicaid, BCBS and Managed Care (third party payors) applications simultaneous to hospital privileging process:
- Collaborate with both regional Operations personnel as well as Providers directly to secure provider enrollment applications in a timely manner.
- Process, complete and submit provider enrollment applications to the Insurance Carrier within specified time frame to avoid write off of charges and maximize reimbursement
- Participate on bi-weekly conference calls with Division and Regional personnel to address and strategize on outstanding enrollment issues
- Provider's Liaison to Billing Company on enrollment and claims related issues
- Follow-up with insurance plans to secure provider approval through provider number (PIN) assignment.Enter approval information into Sales Force so billing company can be notified to release claims.
- Managed Care Department Interaction
- Work with Managed Care personnel to ensure timely enrollment with managed care plans to maximize reimbursement and minimize patient complaints related to participation status
- Provider Enrollment Specialist has access to confidential and protected patient information and must handle sensitive information in accordance with company protocol and HIPAA rules and regulation.
- Monitor carrier website for forms revision and update master provider enrollment packets as needed
- Advise management of issues with carriers/problem providers
- Answer incoming calls in a professional manner
- Maintain clear and concise Enrollment files both in paper form as well as Sales Force
- Maintains a high degree of ethics, integrity, and confidentiality in dealing with employees, and external customers
Provider Enrollment Claims Resolution
- Act as primary contact for Provider Enrollment regarding provider-related claim denials
- Research and resolve provider-related claim denials by contacting payors and communicate results to appropriate Provider Enrollment Manager
- Submit registration info via spreadsheet or form as needed for Medicaid HMO products and keep current
- Document all registration submissions and notes in Sales Force
- Review carrier and industry websites, newsletters, etc to assure thorough understanding of industry standards and changes
Knowledge, Skills, and Abilities:
- Knowledge of Centers for Medicare and Medicaid Services (CMS), Council for Affordable Quality Healthcare (CAQH ) and National Committee on Quality Assurance (NCQA) credentialing requirements is preferred.
- Manage multiple priorities and possess strong organizational skills
- Overall working knowledge of software programs with a drive to incorporate technology in all operational functions
- Ability to analyze data, make recommendations and implement plans
- Results driven
- Drives service and quality excellence
- Ability to foster a cooperative work environment
- Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community
- Knowledge of web page access and utilization
- Ability to communicate effectively both orally and in writing
- Possess critical and strategic thinking skills
- Ability to take initiative and risks
- Certified Professional Medical Services Manager (CPMSM) - Preferred
- Certified Provider Credentials Specialist (CPCS) - Preferred
- Registered Health Information Administrator (RHIA) - Preferred