Job Summary
The primary role of the Provider Enrollment Specialist is to enroll all eligible providers into the various insurance programs including Medicare, Blue Cross Blue Shield, TriCare, Multiplan, CAQH, PECOs and other programs as requested.
Essential Functions - Duties & Responsibilities
Works collaboratively with all providers to complete initial applications for Medicare, Tricare (as applicable), Blue Cross Blue Shield, Multiplan, and other insurer groups as required.
Meets with providers at orientation to explain the provider enrollment process.
Maintains CAQH profile for each provider (quarterly). If a provider does not have a CAQH profile, a request sponsorship of a new account is made to Multiplan.
Creates and maintains PECOs (Medicare system) account for each provider (annually) and attaches it to the LSI account.
Maintains provider data in managed care component of credentialing software.
Completes data entry (of paper applications) with validation of provider submitted enrollment information to insure the enrollment application meets the minimum standards
Sends out deficiency letters to notify providers of incomplete/inaccurate applications. Corrects existing deficiencies based on QA audits.
Responds to inquiries regarding status of applications received .
Research sand contact providers to resolve enrollment application deficiencies .
Sends out provider applications, forms and other provider correspondence as requested.
Maintains Provider Enrollment Policies & Procedures.
Adheres to Quality Assurance program in order to improve daily processing of applications and file maintenance transactions with a minimum quality score of 98%
Provides monthly reports to leadership, compliance, and financial services regarding current enrollment status of providers.
Works with providers to troubleshoot any issues that should occur with enrollment status.
Maintains strict confidentiality of information and job files as dictated by current HIPAA requirements.
Maintains strict confidentiality of the credentialing files and information contained therein.
Works with legal team to ensure most current information regarding any legal or administrative claims are available to the provider at time of renewal.
Flexibility to work overtime as dictated by daily production inventory requirements
Demonstrates understanding and commitment to the corporate compliance programs as adopted by Laser Spine Institute and its affiliates.
Performs in accordance with established continuous quality improvement policies and procedures.
Contacts the Compliance officer with regard to any issues arising from enrollment of provider into medicare or any federally funded program.
Demonstrates understanding of importance of accurate record keeping and confidentiality of all records pertaining to the enrollment and credentialing process.
Establishes a system for collecting and organizing data to be used in monitoring all enrollment files.
Responsible for confidentiality of all records and ensures access to these records is limited to authorized individuals.
Additional duties as assigned
Qualifications & Requirements
Required Qualifications:
Education:
- High school diploma
Experience:
- 3+ years in provider enrollment including implementation and ongoing oversight of provider enrollment and all applicable federal laws pertaining to federally funded programs.
License/Certifications:
- N/A
Preferred Qualifications:
Education:
- 2+ years college
Experience:
- Web-based credentialing software
License/Certifications:
N/A