Payor Audit & Enrollment Specialist

Dental Care Alliance•Sarasota, FL

3d•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, maintains audit readiness against payor and accreditation standards, and governs provider enrollment and billing data within DentalXchange and connected systems. Working under general direction, the Specialist interprets payor contracts, delegation agreements, and regulatory requirements; exercises independent 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 across 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 position 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 suitable for confidential information. The role collaborates virtually with internal teams and communicates with payors, delegation oversight teams, and the clearinghouse vendor. Standard business hours apply, with occasional extended hours for audit deadlines or schedules. Limited travel may be required for department or organizational meetings.

Requirements

High school diploma or equivalent.
Six or more years of progressively responsible experience in dental or medical credentialing, payor enrollment, or healthcare revenue cycle.
Demonstrated ownership of a program, process, or system rather than 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.

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 subject-matter expert and point of contact for payor-initiated audits, coordinating with the Credentialing Manager, who retains overall accountability for audit representation.
Evaluate audit requests to determine scope, exposure, and response strategy; design and administer centralized audit intake, risk-tiering, and tracking.
Analyze practice, billing, and clinical records; construct the factual record; and author and submit formal written responses to payors.
Exercise judgment on audit response positioning, disclosure, and remediation commitments, engaging Legal, Clinical, or Compliance partners when warranted.
Negotiate response timelines and extension requests with payor contacts and escalate material risks with recommended courses of action.
Analyze audit outcomes, root causes, and turnaround performance, and recommend provider education, workflow redesign, and policy changes.
Own the delegated credentialing audit program and translate delegation agreement obligations into internal standards, controls, and monitoring routines.
Lead technical execution of pre-delegation and periodic delegated 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 policies, procedures, and committee documentation.
Draft and recommend corrective action plans, drive approved plans to closure, validate sustained correction, and advise leadership on delegation risk and evolving standards.
Serve as system subject-matter expert and data owner for provider enrollment information within DentalXchange, establishing data standards, validation rules, and audit controls.
Define and maintain the end-to-end enrollment workflow across credentialing, contracting, and clearinghouse activation, including service-level expectations and hand-off criteria.
Perform recurring data integrity reviews reconciling demographic, NPI, tax ID, and enrollment data against source credentialing records; diagnose complex 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 submission and continuous audit readiness across practice locations.
Reconcile payor enrollment and effective-date records against credentialing and contracting status to identify denial or take-back exposure before claims are submitted.
Analyze denial and rejection trends related to enrollment or credentialing defects, quantify financial impact, and recommend corrective process or system changes.
Maintain documentation supporting billing-related audit responses, including fee schedules, enrollment confirmations, and EDI/ERA records.
Partner with Billing and Revenue Cycle leadership to prioritize remediation and advise on go-live readiness for new providers and acquired practices.
Build and maintain reporting on audit volume, outcomes, cycle time, delegated audit results, and enrollment data quality; present findings and recommendations to relevant partners.
Recommend and maintain key performance and risk indicators, monitor performance, and propose thresholds and corrective action where results fall short.
Monitor regulatory, accreditation, and payor policy changes and implement required 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 policy and process changes for Credentialing leadership approval, and provide technical leadership and work direction to less-experienced staff.