Healthcare Enrollment Specialist Job Descriptions, Average Salary, Interview Questions

Responsibilities

• Conducts health insurance options education at the appropriate agency and community sites. Attends community meetings and training as needed
• Documents contacts, maintains files, and submits program statistics as needed. Utilizes an enrollment verification system to document outcomes. Timely and complete submission of project logs/data reports
• Meets department application assistance productivity standards of 4 applications per day
• Performs other duties as assigned
• Provides health insurance eligibility determination and application assistance at assigned clinics and community sites

Qualifications

• Ability and means to travel as needed in a timely manner within (City) County, to locations that may have limited access to public transportation; proof of liability and property damage insurance on vehicle used is required
• Certified Enrollment Counselor Certification must be obtained within 90 days of hire and maintained while in this position
• High school graduate or GED equivalency required

Experience

• Ability to work effectively with other organizations
• Ability to work effectively with patients from diverse social, cultural, and economic groups
• Ability to work independently and use critical thinking skills
• Basic knowledge of Medi-cal, Medi-Cal Managed Care Plans, Covered California, CalFresh, and private insurance
• Bilingual in English/Spanish required
• Excellent interpersonal and customer service skills
• Intermediate Written and verbal communication skills

Summary

The Payor Credentialing and Enrollment Specialist will accomplish the following functions for billable employed physicians, allied health professionals, or contracted providers associated with ABC Company.

Education

• Bachelor’s Degree preferred but not required

Experience

• Minimum of 3 years experience in a healthcare environment with direct related credentialing or payor enrollment experience required
• Ability to master and employ a variety of complex procedures, methods, and processes to perform provider credentialing and enrollment functions
• Knowledge of NCQA/URAC standards preferred
• Knowledge of Joint Commission standards is preferred. Knowledge of online enrollment systems such as PECOS and credentialing databases such as ECHO and/or Symed

Job responsibilities

• Initiate and maintain ABC Company hospital credentialing for all providers in the group
• Initiate and maintain payor enrollment for providers
• Facilitate other hospital and/or facility membership for group providers as indicated
• Prepare initial credentialing and re-credentialing files to be presented to the Credentialing Committee in a timely and expeditious manner
• Initiate and maintain provider payor enrollment as assigned
• Ensure accuracy and completeness of provider applications whether paper or electronic
• Complete and maintain the CAQH profile for all assigned billable providers including re-attestation every 90 days
• Provide regular updates to the payors of changes in billable provider demographics, practice locations, name changes, etc.
• Prepare reports of provider data for distribution to internal and external customers
• Monitor expirables including license, DEA, board certification, and malpractice, and provide current copies to all payors at the time of renewal
• Maintain accurate and concurrent updates and tracking for each provider to reflect the history of a provider’s credentialing and enrollment status
• Resolve complex issues relating to provider credentialing
• Respond to requests by external and internal entities regarding issues pertaining to the status of credentialing and/or enrollment of providers
• Accurately completes applicable facility (hospital, surgical centers, etc.) applications for signature by the affected provider
• Follow up with the facility routinely to ensure information is complete and accurate and that the facility is aggressively processing the application
• Prepare facility re-credentialing applications on all assigned providers
• To model ABC Company’s mission and values at all times

Skills and abilities

• Problem-solving skills and ability to explore all options and use available resources to find new and effective solutions
• Strong organizational, critical thinking, and problem-solving skills required
• Ability to communicate appropriately and effectively with providers, including sensitive and confidential information
• Must be able to prioritize and meet deadlines on an ongoing basis to ensure timely completion according to process requirements
• Exhibits sound judgment and hold themselves up as a role model and mentor

Physical demands

• The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion
• Must have good balance and coordination
• The physical requirements of this position are: light work – exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently
• The employee is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures, transcribing, viewing a computer terminal, or extensive reading
• The conditions to which the employee will be subject in this position: The employee is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work

Job summary:

The Provider Enrollment Specialist is responsible for coordinating, monitoring, and maintaining the provider enrollment and re-enrollment process in a timely and compliant manner with all government and commercial payors. Facilitates all aspects of provider enrollment, including initial enrollment, re-enrollment, monitoring, and appointment for the medical staff and allied health practitioners. Assists with problem identification and timely resolution of payor-related issues surrounding claim submission and denial management to ensure optimal reimbursement. The position serves as the liaison between managed care plans and ABC Company, including Revenue Cycle Operations and the Faculty Group Practice, to resolve any billing issues related to provider enrollment and promote optimal reimbursement.

Responsibilities:

• Facilitate enrollment of new ABC Company providers to ensure proper and timely billing and collections
• Prepare enrollment applications for all health plans including Medicare and Medicaid
• Complete data entry and processing of enrollment applications, with validation of provider-submitted information to ensure the application is complete, accurate, and meeting ABC Company standards
• Obtain licensure, certification, and insurance certificates at the time of enrollment and maintain them in the database in order to submit enrollment applications
• Maintain timelines on enrollment processes, and address and/or escalate any delays
• Ensure that all pending enrollments are reviewed, obtained, and managed according to the rules and policies of the department
• Provide monthly notification of new providers, resignations, and changes in provider status such as practice locations and panel status to contracted plans
• Follow up with necessary contacts, including providers and managed care organizations, to resolve enrollment application issues and deficiencies
• Facilitate resolution of provider-related denials to ensure appeal procedures are followed to result in proper reimbursement
• Demonstrate a level of competence and understanding of all state and federal laws, rules, and regulations according to payer guidelines for billing
• Respond to internal and external inquiries on routine enrollment and contract matters, as appropriate
• Perform detailed follow-up activities on assigned accounts according to procedures
• Resolve outstanding AR accounts at a defined level of productivity
• Maintain confidentiality of all provider enrollment business/work and medical staff information
• Prioritize and complete all work in an accurate, effective, and efficient manner
• Participate in team meetings/activities and support the philosophy and goals of the team and department
• Participate in special projects/assignments
• Read all announcements and relevant communications relating to job duties
• Successfully complete competency-based training and testing
• Perform related duties as required

Knowledge and skills:

• Knowledge of insurance claim processing and third-party reimbursement
• Knowledge of state and federal regulations as they pertain to billing processes and procedures
• Ability to understand and interpret statistical reports and perform quantitative analysis
• Knowledge of the principles of Information Systems in order to effectively analyze and make decisions, preferably with experience in Epic and database management
• Skill in effective oral, written, and interpersonal communication
• Skill in time management and project management
• Ability to work efficiently under pressure
• Ability to operate a computer and related applications
• Ability to work independently and take initiative
• Ability to demonstrate a commitment to continuous learning and to operationalize that learning
• Ability to deal effectively with constant changes and be a change agent
• Ability to deal effectively with challenging situations
• Ability to willingly accept responsibility and/or delegate responsibility

Education and experience:

• Associate’s Degree or equivalent and three years of financial, credentialing, billing, or related experience in a healthcare organization