The Provider Enrollment Specialist facilitates the application from a new provider through all stages in order to enroll the provider with commercial and/or government payers as well as facilities. The Specialist is also responsible for updating practitioner information in both the internal software and with external payers. In addition to data entry, the specialist also maintains copies of licensure, certificates, and other documents necessary for the enrollment process, maintains provider CAQH profiles, and conducts verification of all data, ensuring accuracy and timely entry of information. The specialist shares essential updates with providers and the internal team as necessary in weekly summary reports.

Job Responsibilities:

Assembles and maintains current and accurate data for all practices and providers.

Ensures timely processing of all credential requests.

Coordinates with providers to obtain signatures and documents necessary for completion of process.

Completes practice and provides credentialing and re-credentialing applications; monitors applications and follows-up as needed.

Ensures practice demographic and addresses are current with health plans, agencies and other entities.

Ensures Billing Team is aware of when a provider is enrolled with insurances via email.

Assists Billing Team with troubleshooting accounts with contract related issues.

Maintains a spreadsheet detailing which insurance practice and providers are credentialed with.

Communicate credentialing status to Providers, Department Mgrs. and COO

Assist provider with obtaining medical/professional licenses multiple states.

Remain current with Medical Nursing Board Act

Ensures all providers are in compliance with their respective state laws. Create and update protocols and coordinate Quality Improvement Evaluation (QIE) conferences and maintain reports.

Create and keep up with all provider’s Council for Affordable Quality Healthcare (CAQH) profiles, attesting quarterly.

Order correct malpractice insurance, maintaining certificate information current as providers are hired or resigned.