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Responsibilities:- Group Enrollment & Updates: Process, update, and confirm group EDI/ERA/EDI enrollments via hard copies or payer portals, ensuring accuracy and efficiency.
- Provider Enrollment & Recertification: Manage the initial provider enrollment and recertification process for employed and contracted practitioners, including collaborating with physicians, nurse practitioners, and Locum Tenens.
- Data Management & Maintenance: Ensure timely and accurate data entry for practitioner information in the credentialing database; periodically revise and update practitioner records. Maintain electronic data files and use the CAQH system for submitting practitioner information to client health plans.
- Health Plan Enrollment: Enroll practitioners with appropriate client health plans and monitor the progress of each enrollment.
- Government Payer Enrollment: Facilitate enrollment with government payers using electronic methods such as PECOS and payer portals.
- Document Monitoring & Compliance: Monitor the expiration of licensure, board certifications, and other critical documents for practitioners, ensuring compliance with established policies and procedures.
- Issue Resolution: Identify, analyze, and resolve discrepancies, time gaps, and other issues that may impact the ability to enroll practitioners.
Requirements:- Experience: A minimum of 2 years in healthcare and enrollment services.
- Payor Portal Expertise: Knowledge of payor portals for group and provider enrollments, as well as EDI/EFT/ERA processing.
- Billing & Claims Familiarity: Understanding of practitioner billing and claims payment system requirements in relation to practitioner enrollment.
- Critical Thinking & Communication: Strong critical thinking skills, sound judgment, and the ability to communicate clearly with practitioners, administrators, and client credentialing personnel.
- Technical Skills: Proficient in Microsoft Office and Excel.
- Credentialing Software: Prior experience using credentialing tracking software such as Verity or Modio.
Preferred Qualifications:- Athena Billing Systems: Experience with Athena billing systems is a plus.
- Medical Enrollment & Staffing: Previous experience in medical payer enrollment, medical staffing, and privileging.
- Certification: Certification in Credentialing/Enrollment services is preferred.
- Regulatory Knowledge: Familiarity with National Committee for Quality Assurance (NCQA), URAC, and The Joint Commission guidelines and standards related to provider enrollment.
Date Posted: 11 April 2025
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