Provider Enrollment Specialist Resume Samples

Description :

1. Worked on Special Projects and New Merger and Acquisition Site Set-Ups.
2. Working one-on-one with physicians and advanced practice providers, site managers, business account managers and payers.
3. Ensuring the site and providers at that location are set up correctly for billing purposes.
4. Coordinated the credentialing process for providers to ensure the timely and efficient flow of reimbursement for services and the completion of internal and external requirements.
5. Primary liaisons between payer companies and Sanford Health in communicating provider information to ensure providers were properly credentialed to receive reimbursement.
6. Analyzed all aspects and details of credentialing applications and re-credentialing to ensure the accuracy and validity of provider credentials. 
7. Facilitates required documentation collection from providers.
8. Interacted with providers, senior management, and other appropriate associates to answer questions, and facilitate the application process in a confidential manner.
9. Maintained an electronic credentialing system to ensure accurate and confidential provider information is available on an on-going basis.

Experience

7-10 Years

Level

Management

Education

Associate

Description :

1. Responsible for review and pre-assessment of medical staff clinical privileges requested and subsequently the accuracy and integrity of the database system.
2. Liaison between the providers, medical staff office and related entities regarding credentialing, malpractice coverage, and provider enrollment.
3. Facilitates all aspects of credentialing of medical staff applicants and reappointment of existing medical staff to ensure completeness and timeliness.
4. Maintain and work reports of non-compliant providers and held A/R.
5. Facilitate provider enrollment for various government healthcare payers and third-party billing entities.
6. Responsible for enrolling providers into Medicare and Medicaid EHR incentive program.
7. Responsible for providing JPSPG Administration and Department Chairs with updates regarding changes with government healthcare payers and third-party billing entities.

Experience

10+ Years

Level

Senior

Education

Associate

Description :

1. Provided expertise on insurance and healthcare over the phone.
2. Contact payers for authorization to practice site(s), providers file and active excel spreadsheets.
3. Develops and implements general insurance and health policies in accordance with the state and federal laws.
4. Provides expertise to investigate and adjudicate claim characteristics that do not match policy provisions.
5. Primary responsibilities include but not limited to processing provider enrollment applications from receipt to inclusion along with the file maintenance.
6. Includes accurate and timely entry of provider data provider applications and demographics.
7. Verifying all the credentialing criteria for a practitioner and has applied both initial and re-credentialing as needed.
8. Enter and maintain provider applications, contracts, and updates into the system.
9. Perform ongoing research to correct data so it does not create duplicate provider, locations, payees and participations.
10. Maintain credentialing information by reviewing, entering and following up on missing information.

Experience

5-7 Years

Level

Executive

Education

Certification

Description :

1. Works closely with external Provider Enrollment vendor on notification of a providers start, welcome packets, provider documentation and ensuring the provider is in all systems.
2. Performs follow-up with insurance payers via phone, email or website to resolve provider enrollment issues.
3. Manage the completion and submission of provider enrollment applications.
4. Perform tracking and follow-up to ensure provider numbers are established and linked to the appropriate group entity.
5. Understand specific application requirements for each payer including pre-requisites, forms required, form completion requirements, and regulations.
6. Maintain documentation and reporting regarding provider enrollments in process.
7. Work closely with program site management to expedite completion of forms and requirements including obtaining signatures, locating required documentation, etc.
8. Establish close working relationships with credentialing coordinators, contracting department, medical management, and payer contacts.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Review provider enrollment packets for missing information; requests missing information are from the provider.
2. Resolves discrepancies between information supplied and findings of other sources (NPDB, State Dental Boards, etc.).
3. Build provider records and enter the relevant information into the credentialing database and other ancillary data repositories as needed.
4. Ensured the provider's credentials comply with requirements of contracted payers and as well as preparing provider's files for the credentialing committee.
5. Maintains up-to-date database, including medical licenses, drug enforcement administration certificates, provider numbers and renewal period expiration dates.
6. Confirm all required verifications are complete and have been performed according to the required standard and within required timeframes.
7. Researched detailed information on provider status in response to telephone or written inquiries.
8. Researched and analyzed problems' with enrollment packet and recommend resolution.

Experience

7-10 Years

Level

Management

Education

Certification

Description :

1. Review applications for completeness of information, identify deficiencies with follow up to the provider to pursue incomplete information.
2. Create spreadsheet databases to document and track the current statuses of the application process.
3. Create individualized folders for each provider that contains all incoming and outgoing documents related to the enrollment or the changes which impact the provider's status.
4. Act as a resource to others and proactively resolve provider enrollment issues.
5. Perform a variety of administrative duties such as initiate calls, receive calls, process incoming mail, facsimile verifications, scan, file, copy and other duties as needed.
6. Monitor and update CAQH with accurate and up to date information and upload support documents.
7. Checking licenses, creating paperwork, gathering signatures and documents.

Experience

10+ Years

Level

Senior

Education

Certification

Description :

1. Responsible for performing administrative and technical duties requiring accuracy, and attention to detail in the provider enrollment department.
2. Responsible for all aspects of the payor enrollment process for health care providers.
3. Monitors changing insurance enrollment rules/regulations to ensure enrollment compliance.
4. Obtains and reviews copies of practitioner's licenses, and certifications, DEA, CDS, etc to ensure Credentials are current within compliance guidelines.
5. Coordinate all managed care enrollment activities to ensure provider participation status.
6. Enrollment activities require substantial contact with outside agencies.
7. Prepare and complete enrollment and re-enrollment applications on behalf of physicians/providers for Submission to managed care companies and other governmental agencies.
8. Maintain necessary logs, lists records, and current documentation required for physician/provider Enrollment and re-enrollment.

Experience

10+ Years

Level

Senior

Education

MBA

Description :

1. Research and resolve enrollment and billing issues that are on the vendor hold report.
2. Work closely with the providers and Hospital staff to ensure that all documents needed to enroll get returned timely.
3. Submit all-payer applications and required documentation to the insurance payer and perform tracking and follow up to ensure provider numbers are issued and the provider is linked to appropriate group numbers.
4. Adding providers and entering provider numbers into AthenaNet and marking them PAR so that claims can be processed.
5. Maintain provider records for all completed enrollments.
6. Perform re-credentialing of providers that are required by the payers.
7. Works closely with the contracting department to ensure that enrollment is completed for the providers for each new contract that is executed between Sound and the payers.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Reviewed and approved provider out-of-state Medicaid applications based on business rules and licensure.
2. Ensured Healthcare providers were in compliance with all federal and state rules, regulations and policies.
3. Performed all data entry functions by entering in the provider enrollments into an MMS system (Medicaid Management Information System).
4. Performed Data Entry to update and/or change the provider's name or address information to keep accounts current.
5. Processed incoming and outgoing mail received from multiple providers.
6. Answered provider calls and researched inquiries in a timely manner regarding the enrollment status.
7. Make follow up calls, and maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.
8. Utilized state online enrollment systems and complete paper enrollment applications.

Experience

2-5 Years

Level

Junior

Education

Associate

Description :

1. Manage the completion and submission of provider enrollment applications.
2. Perform tracking and follow-up to ensure provider numbers are established and linked to the appropriate group entity in a timely manner.
3. Understanding specific application requirements, supporting documentation and regulations.
4. Maintaining documentation and reporting regarding provider enrollments in process.
5. Work closely with program site management and corporate resources to expedite completion of forms and requirements locating required documentation.
6. Maintaining provider enrollment information within the credentialing database.
7. Learned to work very closely with other departments to reach a common goal.

Experience

0-2 Years

Level

Junior

Education

Associate

Description :

1. Ensured the timely enrollment of new providers with 3rd party payors, and maintenance of existing active physicians.
2. Accountable for overseeing and for directly updating provider data in the CAQH system, as necessary.
3. Submitted termination requests to all health plans in a timely manner.
4. Ensured the timely enrollment of new providers with the governmental payors including but not limited to Medicaid/ care.
5. Responsible for all the on-going maintenance of existing providers including but not limited to the submission of maintenance forms to update personal and practice demographic data for providers, billing updates.
6. Inputted provider enrollment information into IDX, MSO and Provider Enrollment Database systems.
7. Distribution of information to designated department representatives and credentialing and administrators.

Experience

5-7 Years

Level

Executive

Education

BS

Description :

1. Prepared new provider enrollment applications for all health plans including Medicaid and Medicare.
2. Oversaw the credentialing and re-credentialing processes for new and current providers.
3. Served as the primary liaison between physicians, administrators, staff, payers, and providers.
4. Assisted and guided new providers in completing applications and obtaining required documents.
5. Resolved internal inquiries and issues regarding provider enrollment, provider updates, billing, credentialing, and many other issues.
6. Completed recurring periodic updates for provider licenses, malpractice coverage, board certificates, and other required documents.
7. Updated accounts and resolved claim denials and rejections in Epic work queue.
8. Completed Medical Staff applications, Non-Staff access, and other forms.

Experience

7-10 Years

Level

Management

Education

BS

Description :

1. Analyzes supporting documentation received from healthcare providers to determine compliance with federal, state and local laws.
2. Reviews provider enrollment applications for completeness and accuracy.
3. Verifies provider's demographic and programmatic information indicated on the application utilizing various internet tools and research methods.
4. Initiates the composition of correspondence to the provider community as required by Medicaid policy and procedures.
5. Appropriately document systems and files in the MMIS system.
6. Monitor credentialing and re-credentialing applications in Microsoft Excel.
7. Understanding of program and technical operation with federal, state and local laws and regulations.
8. Resolves and facilities the resolution of problems and difficult situations independently.

Experience

2-5 Years

Level

Junior

Education

BBM

Description :

1. Compiled, copied, sorted, and filed records of office activities, business transactions, and other activities.
2. Communicated with prospective clients and other individuals to disseminate and explain information regarding enrollment in health plans.
3. Completed client enrollment and arranged appointments for clients to discuss services for individuals, families, and small businesses.
4. Reviewed files, records, and other documents to obtain information to respond to requests.
5. Answered telephone, responded to requests, and met with individuals in person on a daily basis.
6. Computed, recorded, and proofread data and other information, such as records and reports.
7. Distinguished for providing the superior level of customer service to clients.

Experience

2-5 Years

Level

Junior

Education

BA