The Payor Enrollment Specialist administers the enrollment process for participation into Governmental and Commercial payor agreements for the health system, practice locations and individual Physicians or other Health Care Professionals.

This person is responsible for ensuring adherence to CMS and NCQA standards, individual payor network requirements, functions of delegated credentialing, performance of practice site audits, payor director reviews, initial enrollment applications, follow-up, and revalidations.

In this position, you will interact with employees on all levels of the organization, insurances and clients and their support staff. The ideal candidate will be highly detailed and will be adept at navigating multiple online systems and resources. You're a strong communicator with internal and external customers, have solid organizational skills, and can apply your analytical skills to solving challenges. You also exhibit the ability to think critically about process workflow and the best use of supporting systems.

Our values of Excellence, Empathy, Integrity and Accountability are essential to exceed our customers’ expectations. At Reid, we look for individuals who believe in our core values and demonstrate a genuine desire to make a positive impact to those we serve.  We take pride in employing people who show up every day with a commitment to these values along with our mission and vision. We are one team working toward a common goal of providing outstanding customer care and service to our communities. If you have a calling to serve and are looking for meaningful and purposeful work, Reid Health is the place for you.

To lead our communities to well-being, one person at a time. It is not just what we do – it is who we are.

1. Ensure provider participation with contracted payors by taking appropriate next actions to complete enrollment, such as completing applications, rosters, and notifications.
2. Ensures a detailed process and through review of the accuracy of the information used to submit enrollment applications.
3. Identifies any discrepancies or adverse information noted from applications, primary source verifications or other sources utilized for enrollment functions. Ensures discrepancies are addressed promptly and the proper follow-up is completed timely.
4. Submits data and applications to the contracted and government payors in a manner commensurate with their individual expectations, policies and accreditation standards.
5. Communicate enrollment status to all stakeholders in a clear and timely manner and providers reports to stakeholders as necessary.
6. Performs any revalidations, using available verification sources, to ensure compliance with accreditation and regulatory standards.
7. Performs external queries with payors regarding practitioner’ status, providing responses in a timely manner.
8. Performs practice-site visits in accordance with NCQA and payor plan requirements.
9. Contacts medical staff members to relay information or obtain approval on specific issues.
10. Manages the provider master file, ensuring staff are aware of incoming and outgoing providers.
11. Update and maintain data in appropriate Provider Enrollment systems while ensuring accuracy and data integrity.
12. Performs delegated credentialing functions.
13. Initiate contact with payors and practices via telephone or electronic methods with respect to provider enrollment and billing errors, utilizing proper customer service protocol with results communicated to the Revenue Cycle department.
14. Reviews individual payor manuals and bulletins to ensure compliance with enrollment process.
15. Review correspondence received and perform appropriate action to resolve when needed.
16. Accomplishes provider enrollment/ disenrollment operations, including application review, entering applications into system and submissions to CMS and third party insurance coverages. Obtains missing information for enrollment completion. Coordinates process within applicable timeframes.
17. Prepare the CAQH re-attestations for existing providers
18. Research and resolve provider related enrollment issues and coordinate with members of various departments when applicable.
19. Maintain the physician’s files for revalidation of Medicare via PECOS and other applicable systems/databases.
20. Maintains documentation and reporting regarding payer enrollments in process
21. Ensure the timelines for provider enrollment to payers.
22. Initiate and track provider enrollment with insurance companies.
23. Follow-up with insurance companies regarding provider participation status
24. Participate in department meetings, learning opportunities; strive to meet quarterly department quality indicators and personal goals
25. Cooperates with others to balance the workload and meet project deadlines of the department
26. Will provide back-up to the Credentialing Specialist position responsibilities, such as processing initial application for privileges, medical staff reappointment and maintaining expirations.

Education Required:  High School diploma required

Education Preferred:  Associates Degree in business or healthcare related field or applicable experience

Experience Required:  Healthcare experience

Experience Preferred: 2+ years experience in payor enrollment.  Medical terminology preferred.

Licensure: N/A

Certifications:  Credentialing certification (CPCS) recommended, not required.

Other:  N/A

Unexpected Perks - Daycare, Doordash, SmartDollar, Daily Pay, therapy dogs, massages, Forbes rated Best Places to Work 2022

Not quite what you are looking for? Submit your information here for general consideration. One of our employment specialists will be in touch with next steps.

EEO Statement: Reid Health is an Equal Opportunity Employer

No Search Firms:

Reid Health does not accept unsolicited assistance from search firms for employment opportunities. Please do not call or email. All resumes submitted by search firms to any employee or other representative at Reid Health via email, the internet or in any form and/or method without a vaild written search agreement in place and approved by HR will result in no fee being paid in the event the candidate is hired by Reid Health. 

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