Provider Enrollment Specialist

Spartanburg Regional Healthcare System•Spartanburg, SC

About The Position

The Provider Enrollment Specialist performs enrollment, reassignment, and re-enrollment functions for providers with commercial insurance carriers and government payers. The role serves as a resource and liaison to implement enrollment processes and resolve issues related to reimbursement. The specialist works directly with credentialing teams, payers, employed physicians, and advanced practice clinicians to ensure applications are completed within required timeframes. The position maintains working knowledge of CAQH, PECOS, SC DHHS, NC Tracks, NPPES, and other payer enrollment portals.

Requirements

High school diploma or equivalent.
Two years of applicable experience, or three years of experience working in managed care, credentialing, or revenue cycle.
Proficiency with payer portals and Microsoft Office Suite.

Nice To Haves

Associate degree.
Five years of applicable experience.
Proficiency with credentialing software, payer portals, and Microsoft Office Suite.
Certified Provider Enrollment Specialist (CPES) or Certified Provider Credentialing Specialist (CPCS) certification.

Responsibilities

Obtain, verify, and analyze information required for payer enrollment.
Organize payer enrollment processes to meet required timelines.
Interface with health plan contacts to understand and support credentialing applications and their completion.
Prepare, submit, and track payer enrollment, reassignment, re-enrollment, and demographic update applications.
Follow up with payers to ensure applications are complete.
Track and follow up to ensure provider numbers are established and linked to the appropriate group entity in a timely manner.
Ensure accurate and complete provider data entry in the enrollment system.
Use CAQH, PECOS, SC DHHS, NC Tracks, and NPPES to ensure taxonomy codes are appropriate for provider specialties and billing requirements.
Submit Annual Disclosures of Ownership and Medicare and Medicaid revalidations for assigned providers and practices.
Participate with the team in implementing and following policies, procedures, and systems that support timely data entry in the credentialing platform.
Maintain accurate provider records in the credentialing platform as a single source of truth, supporting data integrity, regulatory compliance, and timely claims processing.
Maintain enrollment information in the credentialing database and provide reports to hospital administration, marketing, professional billing staff, and clinic directors or managers as needed.
Follow objectives, operating policies and procedures, and strategic action plans for achieving goals.
Collaborate with the supervisor to develop processes and procedures that improve overall operations.
Collaborate with the credentialing team to gather provider documentation needed for enrollment.
Communicate application status, required next steps, and potential effects on claims processing to stakeholders.
Identify and review red flags with managers and directors.
Complete mandatory compliance training and learn applicable compliance requirements.
Comply with standards of operations and uphold the organization's commitment to teamwork, communication, empowerment, quality, and data integrity.
Perform other duties as assigned.