Provider Enrollment Specialist

General Description:

Under general direction, initiates provider enrollment activities with federal and managed care plans and is also responsible for initiating and maintaining credentialing and verification needs.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

• Collaborates with Medical Staff Services Credentialing Coordinators to ensure accurate credentialing information is established for providers.

• Collaborates with OU Health Contracting to ensure group contracts are in place and maintained.

• Initiates provider enrollment activities with federal and managed care plans to establish billing privileges and reassign benefits to OU Health group Tax ID.

• Knowledgeable with accreditation standards of the National Committee for Quality Assurance (NCQA) and The Joint Commission (Ambulatory).

• Proficient with utilizing provider data in credentialing database to use for establishment of provider enrollment.

• Proficient with National Plan & Provider Enumeration System (NPPES) to establish surrogacy connections and update provider data.

• Responsible for initiating and revalidating/renewal of enrollments with Medicare via the Provider Enrollment and Chain Ownership System (PECOS) portal and with Medicaid via the Oklahoma Health Care Authority (OHCA) Provider Portal.

• Proficient with the credentialing software utilized for managing the provider enrollment workflow.

• Possess critical-thinking skills to problem-solve enrollment and revenue cycle issues that arise.

• Demonstrate use of discretion with sensitive provider information, such as malpractice history, licensure actions, sanctions, etc.

• Performs follow-up on outstanding applications and/or payer rosters and responds to development or correction requests in a timely manner.

• Participates in health plan delegation oversight audits.

• Keeps Provider Enrollment Manager informed at all times of the status of new/revised or pending practitioner effective dates to revenue cycle delays.

• Accurately maintain all internal systems with appropriate provider and network participation information.

• Complete appropriate steps for updating and maintaining Provider Enrollment Databases and to ensure claims processed timely and accurately.

• Assist other staff in the resolution of provider enrollment issues.

• Monitors and meets goals established for KPI metrics.

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education: High School Diploma or GED required.

Experience: At least 1 year experience in provider enrollment, credentialing, billing or finance setting or other relevant fields in healthcare.

Licensure/Certifications/Registrations Required: NAMSS certification as a Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) is preferred.

Knowledge, Skills and Abilities:

• Knowledge of accreditation standards and legal requirements related to provider enrollment.

• Requires strong verbal and written professional communication to correspond with executive leaders, health care providers, health plan entities, administrative colleagues, and external organizations.

• Knowledge of credentialing software and associated applications strongly preferred.

• Ability to work under minimal supervision and to adapt quickly to changes within the environment.

• Ability to maintain confidentiality.

• Ability to critically think and assess and determine appropriate next best steps in any given situation.

• Proficient with the use of Microsoft Office products for the purpose of meeting monthly, quarterly, and semi-annual payer reporting requirements.