Provider Health Plan Enrollment Specialist

October 2024

SUMMARY:

Under general supervision of billing manager, the provider health plan enrollment specialist is responsible for processing and enrolling health care providers with various insurance networks. This role is critical in ensuring that healthcare providers are accurately enrolled in health plans and meet all regulatory and organizational requirements. The Provider enrollment specialist must have a strong understanding of the credentialing to include provider health plan enrollment and experience in managing provider data.

EXPECTATIONS:

·         Arrives on time and adheres to set schedule.

·         Supports general unit operations through the completion of specific clerical and data entry support duties.

·         Provides support to various departments within the organization

·         Use of professionalism and best efforts in your position.

DUTIES and RESPONSIBILITES

1.0               Provider/Credentialing Management:

1.1               Manage the health plan enrollment process for new current and new healthcare providers, including gathering necessary documentation and completing applications for various insurance networks and government programs (e.g., Medicare, Medicaid).

1.2               Review and maintain provider data in the enrollment database, ensuring all information is current and accurate for billing and credentialing purposes. 

1.3               Conduct thorough credentialing and recredentialing processes for healthcare providers.

2.0               Health Plan Enrollment Coordination:

2.1               Facilitate the enrollment of providers into health plans, including the completion and submission of necessary documentation.

2.2               Maintain up-to-date records of provider enrollment statuses and ensure timely processing.

3.0               Data Management:

3.1               Utilize credentialing software and databases to manage provider information efficiently.

3.2               Perform regular audits of provider files and databases to ensure accuracy and completeness.

3.3               Maintain accurate provider records in the database, ensuring all information is current and compliant with regulatory standards.

4.0               Communication:

4.1               Act as the primary point of contact for providers regarding health plan enrollment and inquiries.

4.2                Collaborate with internal teams, including billing, and Human Resources to streamline processes.

5.0               Regulatory Compliance:

5.1               Stay updated on changes in health plan enrollment regulations and credentialing standards.

5.2               Assist in preparing documentation for audits and regulatory reviews.

6.0               Training and Support:

6.1               Provide guidance and training to new staff on credentialing processes and systems.

6.2               Support providers in navigating enrollment challenges and requirements.

6.3               Identify opportunities for streamlining the enrollment process and implement best practices to enhance efficiency.

7.0               Focus on Corporate Expectations/Standards: 

7.1               Attends and actively participates in all meetings (e.g., team meetings, department meetings, program meetings, employee staff meetings) and other activities as required or assigned.

7.2               Works flexible or extended hours where necessary.

7.3               Demonstrates awareness of, and compliance with, organizational mission and objective of Camarena Health to provide health care access and support services for all members of the community.

7.4               Other work-related duties as assigned by supervisor; duties and responsibilities may be added, deleted, or changed at any time at the discretion of management, formally or informally either verbally or in writing.

7.5               Maintains confidentiality and respect for information regarding providers. abides by Camarena Health Rules of Confidentiality

Minimum Requirements:

Education:          

·         High School diploma or equivalent 

Prior Experience:                             

• Minimum of 2 to 4 years of experience in provider health plan enrollment and credentialing within a healthcare setting. Multi-specialty is a plus. 

Skills:

·         Strong understanding of healthcare regulations, insurance plans, and credentialing processes.

·         Excellent organizational and time-management skills.

·         Proficient in using credentialing software (MedTrainer is a plus) and Microsoft Office Suite.

·         Exceptional communication and interpersonal skills.

·         Strong team player mentality and leadership skills. 

·         Ability to provide work direction to assigned billing personnel thorough knowledge of systems and procedures. 

·         Ability to foster an environment that nurtures collaboration, teamwork, and mutual respect 

·         Ability to work independently and perform critical work under deadlines. effectively with supervisors and other staff. 

·         Good people skills and team work attitude 

Preferred Skills:

·         Ability to work collaboratively in a fast-paced environment

·         Familiar with medical practice management systems (Athenahealth is a plus)

·         Proficient in using credentialing software (MedTrainer is a plus)

Physical Requirements: 

• Must be able to move up to 20 pounds and push up to 50 pounds (on wheels).
• Must be able to hear staff on the phone and those who are served in-person, and speak clearly in order to communicate information to clients and staff.
• Must be able to have vision that is adequate to read memos, a computer screen, personnel forms and clinical and administrative documents.
• Must have high manual dexterity.
• Must be able to reach above the shoulder level to work, must be able to bend, squat and sit, stand, stoop, crouching, reaching, kneeling, twisting/turning, fingering and feeling.