A Brief Overview

The Provider Enrollment Specialist is responsible for enrolling UHMP/UHMG/UHRP/UHUC/LHPG billing providers and hospital-employed APPs with all contracted payers facilitating review of a new provider application from receipt to inclusion for managed care directories. This position maintains accurate and timely updates to the data, including, but not limited to provider applications, contact information, status changes, address changes, payee changes. This also includes verification of all of the credentialing criteria for practitioners that have applied through initial credentialing or re-credentialing. The Provider Enrollment Specialist serves as a liaison between government and commercial payers and physicians, support staff, and all billing entities, while researching and resolving denial situations. The Provider Enrollment specialist serves as a primary contact for internal and external enrollment-related inquiries. Under the supervision of the Manager of Provider Enrollment and in addition to the duties outlined below, this position functions as an agent of the protected peer review process and remains current with appropriate internal and external requirements for performing the duties with high level of quality and compliance. The Provider Enrollment Specialist is responsible for maintaining and developing UHMP/UHMG/UHRP/UHUC/LHPG/Hospital-employed APPs and applicable contracted practitioner relationships.

What You Will Do

• Completes and submits provider enrollment applications electronically for contracted and non-contracted payers in a timely and accurate manner. This includes separate commercial enrollment applications for Dental and Vision providers.
• Maintains timely and accurate data on the Delegated Credentialing Roster by adding physicians to the roster to ensure revenue is received in a timely manner.
• Works and resolves provider enrollment claim edits and denials in a timely manner by collaborating with Delegation, Managed Care, and Central Billing Office teams, while utilizing reports associated with new providers, denied claims, etc. Analyzes and corrects appropriate records for held or denied claims.
• Establishes relationships with internal departments, providers, payers, providers’ office staff and others as appropriate to facilitate proper processing for Federal and commercial payers.
• Follows up with providers on outstanding enrollment information and documents, and with payers to ensure provider identification numbers have been received and are communicated to the payers in a timely manner.
• Facilitates the linking of providers to groups within the billing system.
• Tracks, understands, and completes provider revalidations in a timely manner to avoid lapses in coverage and potential delayed or lost revenue for all providers, including those using Durable Medical Equipment.
• Maintains accurate documentation of all communication with payers and physicians regarding provider enrollment activities.
• Analyzes reports for provider enrollment, re-enrollment and dis-enrollment to measure timely completion in accordance with contract agreements.
• Researches insurance issues and effectively communicates with billing staff and leadership. Performs research with payers for new billing opportunities. Advises management team of any potential delays in enrollment process and works with all parties to resolve issues.
• Works with all Practice Administrators to reconcile provider issues related to the Delegated Credentialing Program. Serves as an internal consultant for UH Leaders as it relates to commercial payer questions and issues.
• Updates and reattests the CAQH on behalf of providers working in various specialties in preparation for submitting enrollment applications to commercial payers.

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.