Provider Enrollment Specialist

Position Title
Provider Enrollment Specialist

Department
Medical Staff/Credentialing

Job Description
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.

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OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.