Provider Enrollment Specialist

Job Description

GENERAL SUMMARY:

As a Provider Enrollment Specialist, you'll play a vital role in our organization's success by managing the complete provider enrollment lifecycle. Working under general supervision, you'll ensure that qualified practitioners are seamlessly enrolled in government programs and commercial health plans, from initial application through directory inclusion and ongoing updates. This position combines data management expertise with relationship-building skills, requiring proficiency in data entry, collection, and analysis while maintaining strict compliance with payer standards and regulations.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Core Enrollment Management:

• Drive the provider enrollment process from application receipt through directory inclusion, managing initial enrollment, re-credentialing, and revalidation with precision and efficiency
• Execute comprehensive and accurate data entry to maintain enrollment database integrity, ensuring all provider information is current and compliant
• Verify all required documentation and information, securing necessary materials to ensure providers are processed according to current policies and procedures
• Issue welcome, denial, or termination letters as appropriate, maintaining clear communication throughout the enrollment journey

Systems & Process Excellence:

• Demonstrate in-depth working knowledge of key payor applications including Webdenis, CHAMPS, PECOS, and CAQH, leveraging these tools to streamline workflow processes
• Execute the Network Management workflow in real time, consistently meeting required turnaround times and accuracy benchmarks
• Document all health plan activities, communications, and follow-up attempts according to department standards, creating a comprehensive audit trail
• Participate actively in system integration and continuous quality improvement initiatives to enhance departmental efficiency

Relationship & Problem-Solving:

• Serve as the primary liaison between payers, clinics, and providers, building strong relationships and ensuring timely, accurate management of participation status
• Research and resolve denied claims and enrollment issues, demonstrating strong analytical and problem-solving capabilities
• Communicate with internal and external stakeholders in a clear, professional, and concise manner, translating complex enrollment requirements into actionable information
• Organize and maintain practitioner files with meticulous attention to confidentiality guidelines and data security

Strategic Contribution:

• Develop in-depth knowledge of health plan standards and departmental procedures, effectively identifying and communicating issues, trends, and concerns to team members and cross-functional partners
• Support the Department Director in developing short and long-range strategic plans, contributing to departmental continuity and organizational objectives
• Demonstrate professional interactions with practitioners and external customers, representing the organization with integrity and expertise

Impact: This role is critical to ensuring providers are appropriately enrolled, compliant, and able to bill for services without interruption, directly supporting patient access and organizational revenue integrity.

Qualifications

EDUCATION/EXPERIENCE REQUIRED: 

•  High School Diploma required. Associate’s Degree preferred. 
• 2-5 years of provider enrollment provider billing or credentialing experience required. 
• High level of energy to work in a fast paced constantly changing environment often including time deadlines, frequent interruptions, multiple demands and multi-tasking. 
• Ability to work under minimal supervision.
• Ability to perform detail work efficiently and with a high degree of accuracy.
• High organized.
• Strong business acumen.
• Excellent verbal and written communication skills.
• Ability to interpret information and make judgments quickly.
• Ability to interact professionally with practitioners and other external customers 
• Strong quantitative and analytical skills.
• Computer proficient in Microsoft Office including: Outlook, Word and Excel.
• Proficient in EPIC, Morrisey.

WORK ENVIRONMENT: 

• Works in a normal office environment where there is no physical discomfort due to temperature, dust, noise, and the like. 
• The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.   
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.