Provider Enrollment Specialist

General Overview

Coordinates and facilitates the enrollment of Allegheny Clinic professional providers with various payers for professional services reimbursement. Reviews provider credentialing and/or recredentialing data for accuracy based on licensing requirements and various insurer payer requirements. Obtains information from professional providers and other sources. Completes timely application processes based on payer specific formats.

Continually follows up on enrollment and/or recredentialing statuses until complete. Resolves issues as they are identified in a timely manner. Maintains systems/applications used in the enrollment processes.

Essential Responsibilities

• Completes provider payer enrollment/credentialing and recredentialing with all identified payers in a timely manner. Handles highly sensitive and confidential information regarding professional providers. (50%)
• 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. (15%)
• Obtains updated provider information from various sources including provider offices, state licensing boards, malpractice insurance companies, residency training programs, etc. Identifies and resolves problems with primary source verification elements by interpreting, analyzing, and researching data. (10%)
• 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 as 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%)
• Continuously searches for process improvements to achieve accuracy and efficiencies. (5%)
• Performs other duties as assigned or required.

Qualifications

Minimum

• 2 years experience in a physician medical practice with a basic understanding of various payer billing requirements and claims processing or experience with payer credentialing/enrollment requirements
• Advanced computer skills using word, excel, adobe and web-based applications
• Excellent customer service, follow-up, and communication skills

Preferred

• Associate’s degree
• Certified Provider Credentialing Support (CPCS) by the National Association Medical Staff Services
• Experience with ECHO and/or professional provider credentialing
• Delegated credentialing experience
• Experience with Cactus and/or other professional provider credentialing software

Compliance Requirement

This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum

$21.97

Pay Range Maximum

$34.39

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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