Provider Enrollment Specialist

JOB DESCRIPTION

The position description is a guide to the critical duties and essential functions of the job, not an all-inclusive list of responsibilities, qualifications, physical demands, and work environment conditions. Position descriptions are reviewed and revised to meet the changing needs of the organization.

TITLE: Provider Enrollment Specialist

JOB OVERVIEW: The Provider Enrollment Specialist is responsible for ensuring Valley Medical Center''s healthcare providers (such as physicians, advance practice practitioners, therapists, clinics, and hospitals) are properly enrolled and credentialed with insurance companies, government healthcare programs, and payer networks to legally bill and receive reimbursement for provider services. This role helps ensure that Valley Medical Center and Clinics receive timely reimbursement and remain compliant with payer requirements.

DEPARTMENT: Medical Staff Services Department

WORK HOURS: Monday - Friday, typically 7:30 a.m. - 4:00 p.m. Some flexibility may be required.

REPORTS TO: Manager, Medical Staff Services Department PRE-REQUISITES:

Associate''s degree required; bachelor''s degree or its equivalent preferred.

Minimum of 2 years of experience in healthcare administration and experience working with commercial and government payors required.

3 to 5 years of experience in healthcare administration and payor-related experience preferred.

Ability to utilize credentialing and enrollment software programs required.

Ability to be self-directed and learn quickly with strong attention to detail required.

Experience with MD-Staff program preferred.

Certified Provider Enrollment Specialist (CPES) certification preferred.

Experience with project coordination and demonstrated ability to prioritize efficiently required.

Thorough knowledge of and respect for the confidential nature of all medical staff services data.

QUALIFICATIONS:

Demonstrate the ability to work independently and maintain strict confidentiality.

Ability to utilize PECOS, NPPES, CAHQ, and One Health Port databases.

Demonstrate excellent interpersonal skills including handling all situations in a professional, positive manner.

Ability to utilize different strategies to resolve conflict.

Demonstrate articulate oral and written communication.

Demonstrate flexibility and ability to manage multiple tasks.

Highly proficient with Microsoft Excel.

Ability to maintain performance in a stressful environment.

9. Ability to meet strict deadlines with good time management and prioritization skills.

UNIQUE PHYSICAL/MENTAL DEMANDS, ENVIRONMENT, AND WORKING CONDITIONS: This role will be responsible for managing the daily workflow and administrative tasks of provider enrollment with proficiency, accuracy and timeliness. Must be able to sit and work at a computer for extended periods.

PERFORMANCE RESPONSIBILITIES:

Generic Job Functions: See Generic Job Description for Administrative Partner.

Essential Responsibilities and Competencies:

Coordinate hospital and provider enrollment and credentialing with health plans, insurance companies, various government healthcare programs, and payer networks in a timely manner to ensure proper payment of Valley Medical Center claims.

Actively engage with payer representatives for issues relating to delegated and non-delegated enrollment and credentialing as requested.

Maintain Valley Medical Center''s delegated roster for monthly distribution to payers.

Maintain current and accurate practitioner information in enrollment databases.

Maintain compliance with Medicare and Medicaid enrollment, revalidation, reassignment of benefits, and ongoing enrollment management.

Track all steps and activity taken in the provider enrollment process to include enrollments, re-enrollments, and provider terminations.

Assist in the review and completion of modified applications for Physical Therapists, Occupational Therapists, Regis