Provider Enrollment Specialist II - Mon - Fri 8:00am - 5:00pm - 100% Remote

Northeast Georgia Health System

1d•Remote

About The Position

This position shall perform complex functions related to the enrollment in Governmental and Commercial plans for Practitioners and/or Facilities at the Northeast Georgia Health System. This includes the processing of all Medicare, Medicaid and Managed Care payor applications, initial & re-appointment. This position also includes responsibility for maintaining and updating the status of all Hospital Outpatient Departments in PECOS. Further this position shall effectively communicate pertinent information to all necessary individuals and entities in a timely and accurate manner. This position has knowledge of a widely used concepts, practices, and procedures. Relies on experience and judgment to plan and accomplish daily work.

Requirements

High School Diploma or GED.
Minimum of three (3) to five (5) years experience working in Provider Enrollment environment to include provider enrollment, credentialing, and/or provider relations or healthcare related setting required.
Experienced working with Medicaid, Medicare, Medicaid CMOs and other governmental payors in enrolling providers/facilities
Experienced with Medicare guidelines for Hospital Outpatient Departments and the utilization of PO/PN modifiers on associated claims.
Accustomed to working with commercial and governmental payors in a delegated arrangement and responding to deadlines
Experienced in credentialing providers with commercial plans following NCQA accreditation standards
Demonstrates a solid understanding of the various operational aspects of managed care to include provider enrollment, credentialing and provider relations
Must be detailed oriented with excellent organizational and computer skills
Must be able to make logical judgments, utilizing independent decision making skills appropriately
Strong written and verbal communication skills and the ability to communicate effectively with people on all levels
Demonstrate ability to function as part of a team, as well as be highly self-motivated
Must have ability to handle multiple projects at the same time, establish priorities and perform under deadline pressures
Exemplifies the organization's customer service standards
Improves work processes
Complies with confidentiality rules, polices, and regulations in all aspects of the job
Demonstrates working knowledge of safety practices
Responds positively to change regarding work.
Demonstrates respect for co-workers

Nice To Haves

Bachelors Degree.

Responsibilities

Enrolls Physicians and mid-level Providers in:(a) commercial plans, and (b) government payor plans to include Tricare, Medicaid CMOs and those that require the Council for Affordable Quality Healthcare (CAQH) .
On an on-going basis, prepares and submits provider enrollment and re-enrollment applications for NGPG Physicians and mid-level providers, in accordance with DOH plans.
Completes all requests for re-credentialing purposes.
Works with the providers and the Practice Managers to facilitate timely completion of applications and submits applications to payors to meet established deadlines in accordance with payor specific documentation and submission requirements.
Works with hospital department leadership to update Facility enrollment for new hospital services provided at off campus locations to ensure accurate Facility enrollment in PECOS and with contracted payors.
Proactively audits and verifies the correct status of identified at risk HOPD services to ensure accuracy and completeness of PECOS records.
Verifies all supporting documents that are needed for enrollment are received from Recruitment and are legible, current and completed correctly.
Follows-up with the provider, the Credentials Verification Office (CVO) and/or Recruitment to secure missing documents.
Monitors provider non-compliance with enrollment requests and notifies management of delays that can impact reimbursement.
Prepares and submits monthly, or as needed, delegated rosters to payors in accordance with delegated agreements to ensure timely effective dates for billing and payment purposes.
This includes new and changed information.
Monitors receipt and follow-through.
Tracks monthly timeliness of provider loads by payor to include date submitted, date confirmation received, error rate and corrections needed.
Reports non-compliance to management for further direction.
Retains communication in an orderly fashion for reference purposes.
Audits on a monthly basis provider loads once confirmed by the payor for accuracy.
Report, by way of written correspondence, the errors that need to be corrected to the payor.
Report findings to management.
Monitor progress and resolution.
Schedule conference call and/or meetings with payor representatives to address issues.
Notifies payors to maintain current provider information including, but not limited to, changes in practice addresses, contact information, name changes, board status and resignations.
Ensures that eleven (11) distinct applications, processes and/or proprietary documents are completed for enrollment purposes, to include the GA Uniform part I and II, CAQH, BCBS, delegated payors, Amerigroup, Peachstate, Wellcare and Tricare, following established internal procedures.
Follows-up on rejected documents from the payors.
Corrects and resubmits on a timely basis.
Retains records for reference purposes.
Completes and submits payor specific enrollment applications and spreadsheets for existing providers that want to add additional practice locations or are moving from one practice to another.
Prepares and submits applications, specific to Anthem, for providers to practice in the Urgent Care centers and prepares proprietary forms required to enroll providers as directed.
Responsible to complete and submit entity applications for Anthem.
Monitors receipt of payor effective date notices.
Contacts payors to follow-up on enrollment status, secure provider numbers, effective dates and confirmation letters.
Enters effective dates and provider numbers on the Medicred.
Scans approval letters into each provider's file for reference purposes.
Notifies key personnel when updates are made.
Enters and updates all provider demographics into Apogee for tracking and reporting purposes.
Notifies the CVO when changes are needed.
Takes the lead with payors in monitoring the progress of enrollment.
Notifies management of payor noncompliance.
Maintains files in an orderly and secure fashion.
Creates e-files to house enrollment documents and related correspondence.
Initiates a provider enrollment tracking form for each provider to monitor progress.
Supports management in all aspects of provider enrollment to include reporting, meeting attendance and department projects as needed.
Tracks carrier requirements as related to provider enrollment to ensure that all regulations are met.