The Provider Enrollment Specialist performs administrative and technical duties requiring accuracy and attention to detail in the enrollment and reenrollment of our organization and its healthcare providers with all managed care networks and government payors (Networks) the organization is contracted with, or has an agreement with, for the reimbursement of services. This position has continuous contact with internal and external customers including physicians and other healthcare providers, administrators, support staff and network representatives. Additionally, this position is responsible for communicating provider participation information to stated internal and external customers through established processes to allow for appropriate patient scheduling and reimbursement for services rendered.
Primary Responsibilities
Accurately complete the enrollment/reenrollment processes as outlined by each network/area for all appropriate healthcare providers as identified through department policies and network reimbursement and delegated contracts to ensure timely and continued provider network participation.
Maintain detailed provider enrollment files in electronic format, including electronically received documents and scanning of hardcopy documents, and document each stage of enrollment/reenrollment process thoroughly.
Accurately maintain all internal systems with appropriate provider and network participation information. Systems including, but not limited to, Qlikview, Epic, Echo, PET and IGUIDE.
Develop and maintain good working relationships with Nemours providers and support staff to obtain necessary and timely information to facilitate the provider enrollment/reenrollment process.
Develop and maintain relationships with Network Representatives in order to facilitate the provider enrollment/reenrollment processes.
Performs follow up with health plans in order to expedite participation approval by each health plan.
Responds to and resolves problems with provider network participation as it relates to denial of services or reimbursement by working closely with all levels of administrative and clinical personnel and network representatives.
Responsible for educating providers, administrators and support staff regarding the enrollment/reenrollment processes and how it relates to the provider's ability to provide care to network members in order to increases reimbursement and reduce patient dissatisfaction.
Work collaboratively with fellow team members to create, evaluate and maintain department workflows, processes, policies and systems. Additionally, each team member is expected to cross train on location and provider type requirements to assist one another in completing assigned duties as the enrollment cycle warrants including special projects
Qualifications:
Associate's degree preferred; High School Diploma or equivalent required