Sr. Provider Enrollment Specialist

Provider Enrollment & Credentialing Responsibilities:

• Manage and execute provider enrollment and recredentialing processes with commercial, Medicare, and Medicaid payers.
• Ensure accurate and timely submission of enrollment applications and supporting documentation.
• Monitor enrollment timelines, proactively following up with payers to avoid delays in reimbursement.
• Maintain current knowledge of payer enrollment requirements, regulations, and industry standards.

Data Management & System Updates:

• Accurately enter and maintain provider demographic and credentialing information in internal databases and payer portals.
• Audit provider files and systems regularly to ensure accuracy and compliance.
• Track and manage license renewals, CAQH attestation, NPI registrations, and other provider data elements required for successful enrollment.

Issue Resolution & Payer Communication:

• Act as a liaison between payers, providers, and internal stakeholders to resolve enrollment issues, rejections, and lapses in network participation.
• Escalate complex issues appropriately while maintaining thorough documentation and communication.
• Collaborate with billing and denial management teams to resolve enrollment-related claim denials.

Compliance & Documentation:

• Ensure compliance with all federal, state, and payer-specific guidelines related to provider enrollment.
• Maintain detailed and organized records of all enrollment activities, correspondence, and approval letters.
• Support audits and internal reviews by providing documentation and insight into provider status.

Collaboration & Cross-Functional Support:

• Partner with Revenue Cycle, Provider Relations, and Credentialing teams to align enrollment efforts with organizational needs.
• Provide subject matter expertise and mentorship to junior team members regarding enrollment best practices and processes.
• Contribute to ongoing process improvements to enhance the accuracy, speed, and efficiency of provider onboarding and enrollment.

Required Qualifications:

• Associate’s degree in Healthcare Administration, Business, or related field required (Bachelor’s preferred).
• Minimum of 3-5 years of experience in provider enrollment, credentialing, or revenue cycle operations.
• Strong understanding of payer enrollment processes for commercial, Medicare, and Medicaid plans.
• Experience working with provider enrollment portals (e.g., PECOS, CAQH, Availity) and electronic credentialing systems.
• Ability to analyze enrollment data and resolve complex payer or application issues effectively.
• Proficiency in Microsoft Office Suite and experience with healthcare information systems (EHR, practice management systems).

Preferred Qualifications:

• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM).
• Experience in a multi-specialty medical group or health system.