Provider Enrollment Specialist

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Remote Eligibility: Candidates must reside and work full-time in AR, KS, MO, OK, or TX before their first day of employment.

General Description:

Under minimal supervision, theProvider Enrollment Specialist IIperforms comprehensive enrollment functions while demonstrating a deep understanding of organizational practice locations and associated group contracts. In addition to executing the end-to-end enrollment lifecycle for federal and managed care plans, this role proactively manages complex clinic data and directly communicates with health plan oversight representatives regardingNCQAimplementation. The Specialist II serves as a senior-level technical resource, creating complex ad-hoc rosters and ensuring that all practice-specific data, including clinic NPIs and group contract numbers, is accurate and current within the organization's billing infrastructure.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities, with or without an accommodation, may result in disqualification from the position.

• Executeall core duties of the enrollment lifecycle, including contract initiation, reassignment of benefits, and the maintenance of billing privileges.

• Manageupdated group practice location information in the enrollment database, including clinic hours, clinic NPIs, group contract numbers, and contact information.

• Leadparticipation in delegation oversight reviews, serving as a technical resource for health plan reviewers and demonstrating compliance with standards.

• Createcomplex ad-hoc reports and rosters within the enrollment software to meet diverse health plan data requests and delegation reporting requirements.

• Communicatedirectly with health plan and delegation oversight representatives regardingNCQAstandards and the organizational implementation of those standards.

• Utilizegovernment and state-specific healthcare enrollment portals to maintain master provider records and complex billing eligibility.

• Directongoing communication with the Revenue Cycle department to resolve persistent enrollment roadblocks and ensure reimbursement accuracy.

• Coordinatethe maintenance of National Provider Identifiers (NPI) within national registries, ensuring seamless integration with health system billing.

• Analyzepractitioner sanctions or adverse disclosures to ensure they are communicated accurately and discreetly to health plans during the enrollment phase.

• Submittimely revalidations and contract renewals, proactively identifying potential gaps in state or federal contract eligibility.

• Optimizethe use of enrollment software to track health plan effective dates and provide real-time updates to organizational stakeholders.

• Resolvecomplex claim holds and denials by investigating deep-rooted credentialing or enrollment discrepancies that affect the revenue cycle.

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education: High School diploma or G.E.D. required.

Experience: At least 3 years of experience in provider enrollment, health plan administration, or medical staff services required.

License(s)/Certification(s)/Registration(s) Required: Certified Provider Enrollment Specialist (CPES) or Certified Provider Credentialing Specialist (CPCS) by the National Association Medical Staff Services (NAMSS) required, or obtained within 12 months of hire.

Knowledge, Skills and Abilities:

• Advanced knowledgeofNCQAaccreditation standards and the regulatory environment governing provider enrollment and delegation.

• Enhanced communication skillswith the ability to navigate discussions with health plan auditors and executive leadership.

• Masteryof healthcare-specific database functionality, specifically in the creation of complex rosters and custom data extracts.

• Advanced understandingof government enrollment portals and national provider registries.

• Proven abilityto manage complex group practice data across multiple locations and Tax IDs.

• Abilityto identify process bottlenecks and implement collaborative solutions to improve enrollment turnaround times.

• Skillin analyzing health plan contracts to determine specific enrollment requirements for a diverse provider population.