MISSION

The Managed Care & Payer Enrollment Specialist is responsible for maintaining individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications.

OUTCOMES

• Complete and communicate network participation forms with various payers and provider enrollments with clearinghouse
• Complete revalidation requests and credentialing/re-credentialing applications to add providers for commercial and government payers, including Medicare and Medicaid.
• Coordinate with CINs to ensure provider credentialing and enrollment applications are submitted timely and accurately
• Apply and update each provider’s accurate service enrollment with Medicaid via GAMMIS and CAQH database file timely according to the schedule published by CMS
• Work closely with all departments within and outside the organization to identify and resolve any denials or authorization issues related to provider credentialing or payer enrollment
• Maintain internal provider grid to ensure all information is accurate and logins are available
• Maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases, including Tax ID and NPI
• Able to effectively conduct research while managing various other functions
• Perform other projects and duties as assigned

COMPETENCIES

Job Related Competencies:

• Action Oriented: Taking on new opportunities and tough challenges with a sense of urgency, high energy, and enthusiasm.

• Plans and Aligns: Planning and prioritizing work to meet commitment aligned with organizational goals.

• Interpersonal Savvy: Relating openly and comfortably with diverse groups of people.

• Manages Complexity: Making sense of complex, high quantity, and sometimes contradictory information to effectively solve problems.