Provider Enrollment Specialist

The Provider Enrollment Specialist role involves managing the administrative process of getting healthcare providers credentialed with insurance companies and government payers like Medicare and Medicaid. Key duties include preparing and submitting applications, tracking their status, maintaining accurate provider records, ensuring compliance with regulations, and following up with providers and payers to resolve issues.

JOB DUTIES

• Prepare and submit enrollment applications and supporting documents for new and existing providers.
• Maintain and update provider information in databases and systems, ensuring accuracy of details like licenses, certifications, and addresses.
• Verify provider credentials and ensure all paperwork meets the requirements of various health plans and government payers.
• Act as a liaison by responding to inquiries from providers and payers, and follow up to expedite the enrollment and re-enrollment process.
• Research and resolve issues that delay enrollment, such as missing information on applications.
• Organize and maintain files for all provider enrollments and other related documentation.

The Provider Enrollment Specialist will possess a strong understanding of healthcare regulations, payer requirements, and provider enrollment processes, along with familiarity with medical terminology and basic billing practices. Technical proficiency is essential, including experience with provider enrollment software, credentialing databases such as CAQH, and common office applications like Word and Excel. Success in this role requires excellent attention to detail, strong organizational skills, and effective communication to manage complex documentation and coordinate with multiple stakeholders. Prior experience in a healthcare setting with at least three (3) to five (5) years of experience is preferred, particularly in credentialing, managed care, or claims processing.