Payor Audit & Enrollment Specialist

Dental Care Alliance•Sarasota, FL

54d•Remote

About The Position

The Specialist – Payor Audit & Provider Enrollment serves as the organization’s subject-matter expert for payor audit response, delegated credentialing oversight, and provider enrollment data integrity. The role manages payor-initiated audits from intake through resolution, determines response strategy, and authors formal responses on behalf of the organization. It leads delegated credentialing audits and maintains continuous readiness against payor and accreditation standards, while governing provider enrollment and billing data within DentalXchange and connected systems. Working under general direction with substantial independence, the Specialist interprets payor contracts, delegation agreements, and regulatory requirements; exercises judgment in assessing and escalating compliance and revenue risk; and develops policies, controls, and reporting for these functions. The position advises Credentialing, Compliance, and Revenue Cycle leadership, partners with practice operations and billing, and provides technical guidance and mentorship to credentialing and enrollment staff. It has no direct reports. This is a full-time remote role supporting a multi-site, multi-state practice environment. Work is performed from a home office with reliable high-speed internet and a private, secure workspace for confidential information. The role collaborates virtually with internal teams and communicates directly with payors, delegation oversight teams, and the clearinghouse vendor. Standard business hours apply, with occasional extended hours for payor deadlines or delegated audit schedules. Limited travel may be required for department or organizational meetings. The position is sedentary and involves prolonged desk and computer work, extensive keyboard, mouse, and monitor use, and frequent telephone, video conference, and email communication. It requires reading, reviewing, and accurately analyzing detailed documentation and data, and occasionally lifting or moving office equipment or files weighing up to 15 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Requirements

High school diploma or equivalent required.
Six or more years of progressively responsible experience in dental or medical credentialing, payor enrollment, or healthcare revenue cycle.
Experience owning a program, process, or system, rather than performing only task-level execution.
Direct, hands-on experience leading or materially supporting payor audits and delegated credentialing audits, including corrective action planning and closure.
Experience interpreting payor contracts, delegation agreements, and NCQA/URAC-aligned credentialing standards and applying them to operational decisions.
Ability to evaluate complex audit, contractual, and enrollment data, identify risks and root causes, and determine appropriate courses of action.
Strong written and verbal communication skills, including authoring formal correspondence and explaining complex compliance and enrollment matters.
Working knowledge of DentalXchange, dental billing, CDT coding, and EDI/ERA processes.
Ability to design, document, and improve audit-readiness controls, policies, and reporting.
Ability to advise leaders and guide less-experienced staff without formal supervisory authority.
Reliable high-speed internet and a private, secure home-office workspace appropriate for confidential information.
Ability to perform sedentary computer-based work, review detailed documentation and data accurately, and occasionally lift or move items weighing up to 15 pounds.

Nice To Haves

Bachelor’s degree in healthcare administration, business, or a related field.
Experience in a multi-site, multi-state healthcare or DSO environment.
CPCS, CPMSM, or comparable credentialing/compliance certification.

Responsibilities

Serve as the point of contact and subject-matter expert for payor-initiated audits, coordinating with the Credentialing Manager, who retains overall accountability for audit representation.
Evaluate audit scope and exposure, determine response strategy, and design and administer centralized audit intake, risk-tiering, and tracking.
Analyze practice, billing, and clinical records and author and submit formal written payor responses, exercising judgment on positioning, disclosure, and remediation commitments; involve Legal, Clinical, or Compliance partners when warranted.
Negotiate response timelines and extensions with payor contacts, and escalate material risks with recommended actions to the Credentialing Manager, Compliance, and operations leadership.
Analyze audit outcomes, root causes, and turnaround performance and recommend provider education, workflow, and policy improvements.
Own the delegated credentialing audit program and translate payor delegation agreements and requirements into internal standards, controls, and monitoring routines.
Lead the technical execution of pre-delegation and periodic audits and serve as the lead technical representative to health plan delegation oversight teams in coordination with the Credentialing Manager.
Conduct internal file and mock audits against NCQA/URAC-aligned and payor-specific standards; determine remediation needs and draft or update credentialing policies, procedures, and committee documentation.
Draft and recommend corrective action plans for Credentialing Manager review and approval, drive approved plans to closure, validate sustained correction, and advise leadership on delegation risk and changing standards.
Serve as the DentalXchange subject-matter expert and data owner for provider enrollment information; establish data standards, validation rules, and audit controls.
Define and maintain end-to-end enrollment workflows connecting credentialing, contracting, and clearinghouse activation, including service levels and departmental hand-off criteria.
Perform recurring data integrity reviews of demographic, NPI, tax ID, and enrollment data against source credentialing records; diagnose complex enrollment rejections, payor edits, and connectivity failures.
Manage DentalXchange support escalations and configuration coordination, and ensure provider status changes are accurately and promptly reflected across connected systems.
Define record-keeping standards and reconciliation cadence to support clean claims and audit readiness across practice locations.
Reconcile payor enrollment and effective-date records against credentialing and contracting status and identify denial or take-back exposure before claims are submitted.
Analyze denial and rejection trends caused by enrollment or credentialing defects, quantify financial impact, recommend corrective changes, and maintain documentation supporting billing-related audit responses.
Partner with Billing and Revenue Cycle leadership to prioritize remediation for providers or locations at risk of billing disruption and advise on go-live readiness for new providers and acquired practices.
Build and maintain reporting on payor audit volume, outcomes, cycle time, delegated audit results, and enrollment data quality; present findings and recommendations to relevant leaders and partners.
Recommend and maintain performance and risk indicators, monitor results, and propose thresholds and corrective actions when performance falls short.
Monitor regulatory, accreditation, and payor policy changes and assess and implement necessary process, documentation, or system changes.
Develop training and reference materials and represent the function on cross-functional projects involving payor onboarding, practice integration, and system implementations.
Set priorities and work methods independently, develop and recommend policies and process changes for leadership approval, and provide technical leadership and work direction to less-experienced credentialing and enrollment staff.