Credentialing – Senior Enrollment Specialist (Hybrid)

Role Summary

The Senior Enrollment Specialist plays a key role in overseeing the end-to-end payor enrollment process. This includes managing applications, ensuring compliance with enrollment requirements, and maintaining accurate records and data. As a Senior Specialist this role serves as a primary contact for enrollment inquiries and addresses complex enrollment issues, playing a pivotal role in issue resolution.

Responsibilities

• Complete knowledge and full understanding of the payor enrollment process.
• Ability to assess unusual and complex circumstances that may occur with enrollment and uses critical thinking and problem-solving techniques to identify and suggest methods for resolution.
• Work is done independently and is reviewed at critical points.
• Responsible for overseeing, monitoring, and maintaining the processes involved in both initial and revalidation of payor enrollment applications.
• Possess a thorough comprehension of payor enrollment requirements and regulations governing enrollment to ensure ongoing compliance.
• Responsible for securing timely enrollment by submitting applications ahead of deadlines and maintaining consistent follow-up with payors through completion.
• Conduct research and document enrollment processes encompassing, but not limited to, initial enrollment, revalidation, and demographic changes.
• Regularly update and manage data in the credentialing database, spreadsheets, and folders, while maintaining data integrity.
• Assures compliance with payor requirements as related to the provider enrollment and monitor activities to ensure compliance with all procedures and regulations.
• Participate in the development and implementation of credentialing processes and procedures and provide input regarding process improvement.
• Serve as primary contact for payor inquiries and issue resolution, specifically related to enrollment and credentialing matters.
• Assist in the training of colleagues on internal enrollment policies and procedures and provide guidance on navigating payor agencies requirements.
• Performs other duties as assigned.

Qualifications

• High school diploma or GED required.
• Four to six years of experience in a credentialing office or equivalent related environments.
• Knowledge of health plan and governmental payor credentialing process and requirements, such as NCQA/state/federal standards, Medicaid, and Medicare.
• Demonstrates proficient communication abilities, both orally and in writing, and strong interpersonal skills.
• Exhibits a heightened level of awareness and attention to detail.
• Demonstrates outstanding organizational and time management skills.
• Demonstrate the ability to work autonomously while effectively contributing to a collaborative team environment.
• Ability to maintain confidentiality.
• Proficient in Database, MS Excel, Word, Adobe and other software systems.
• A team player with multi-tasking capability and strong customer service orientation.

Education

• Bachelor‚Äôs degree preferred.

Skills

• Database management skills including querying, reporting, and document generation a plus.

Physical Demands

• Must possess ability to sit and/or stand for long periods of time.
• Must possess ability to perform repetitive motion.
• Ability to lift up to 15 pounds.
• Majority of work is performed in a desk/cubicle environment.
• Required Training
  • All job specific, safety, and compliance training are assigned based on the job functions associated with this position.

Other

• Travel rarely required.