Senior Provider Network Analyst, Day Shift, Managed Care

Adventist HealthCare•Gaithersburg, MD

1d•Hybrid

About The Position

Adventist HealthCare seeks to hire an experienced Senior Provider Enrollment Specialist for our Managed Care Department who will embrace our mission to extend God’s care through the ministry of physical, mental, and spiritual healing. As a Senior Provider Enrollment Specialist, you will be responsible for overseeing, monitoring, and maintaining the processes involved in both initial and revalidation of payer enrollment applications, including for AHC facility enrollment. You will possess a thorough comprehension of payer enrollment requirements and regulations governing enrollment to ensure ongoing compliance. You will be responsible for securing timely enrollment by submitting applications ahead of deadlines and maintaining consistent follow-up with payers through completion. You will conduct research and document enrollment processes encompassing, but not limited to, initial enrollment, revalidation, and demographic changes. You will regularly update and manage data in the credentialing database, spreadsheets, and folders, while maintaining data integrity. You will assure compliance with payer requirements as related to the provider enrollment and monitor activities to ensure compliance with all procedures and regulations. You will participate in the development and implementation of payer enrollment processes and procedures and provide input regarding process improvement. You will serve as primary contact for payer inquiries and issue resolution, specifically related to enrollment and credentialing matters, including obtaining provider numbers for billing. You will perform other duties as assigned, submit information to IT to load provider numbers and effective dates to billing systems, and update CIN members’ information for the portal. You will collaborate with the Medical Staff Office to address questions, provide updates, and participate in meetings related to provider onboarding, ensuring alignment with organizational policies and payer requirements in accordance with NCQA standards for delegated credentialing. You will actively engage with payers on issues related to enrollment or claims denied for credentialing. You will generate and prepare monthly provider reports of new, updated, and terminated providers for delegated payers. You will collaborate with Provider Recruitment on new service lines and provider onboarding. You will track agreement participation for AHC’s CIN network and oversee delegated credentialing rosters and audits. You will maintain and apply for National Provider Identification (NPI) numbers for entities.

Requirements

Proficiency in Microsoft Office (Excel, Word, Outlook, PowerPoint and Access)
Ability to work independently, prioritize, and manage multiple tasks.
Collaboration skills to work across the organization with key stakeholders.
Working knowledge of payer credentialing, CAQH, ePREP, CMS, etc.
Excellent critical thinking skills
Strong customer service and professional demeanor.
Good verbal and written communication skills.
Strong stewardship of confidential data.
Possess and continuously demonstrate good/sound professional judgment, understanding when and what requires escalation.
Open and receptive to changes that occur.
Providing good feedback on issues of concern and working with the team to implement changes.
Receptive and willing to obtain additional training provided and participate in any associations specific to Payer.
Bachelor’s degree, preferably in Healthcare or Business Administration or 7 to 10 years working experience with provider credentialing and/or enrollment.

Responsibilities

Overseeing, monitoring, and maintaining the processes involved in both initial and revalidation of payer enrollment applications.
Securing timely enrollment by submitting applications ahead of deadlines and maintaining consistent follow-up with payers through completion.
Conducting research and documenting enrollment processes encompassing, but not limited to, initial enrollment, revalidation, and demographic changes.
Regularly updating and managing data in the credentialing database, spreadsheets, and folders, while maintaining data integrity.
Assuring compliance with payer requirements as related to the provider enrollment and monitoring activities to ensure compliance with all procedures and regulations.
Participating in the development and implementation of payer enrollment processes and procedures and providing input regarding process improvement.
Serving as primary contact for payer inquiries and issue resolution, specifically related to enrollment and credentialing matters.
Obtaining provider numbers for billing.
Submitting information to IT to load provider numbers and effective dates to billing systems.
Updating CIN members’ information for the portal.
Collaborating with the Medical Staff Office to address questions, provide updates, and participate in meetings related to provider onboarding, ensuring alignment with organizational policies and payer requirements in accordance with NCQA standards for delegated credentialing.
Actively engaging with payers on issues related to enrollment or claims denied for credentialing.
Generating and preparing monthly provider reports of new, updated, and terminated providers for delegated payers.
Collaborating with Provider Recruitment on new service lines and provider onboarding.
Tracking agreement participation for AHC’s CIN network and overseeing delegated credentialing rosters and audits.
Maintaining and applying for National Provider Identification (NPI) numbers for entities.

Benefits

Work life balance through nonrotating shifts
Recognition and rewards for professional expertise
Free Employee parking
Medical, Prescription, Dental, and Vision coverage for employees and their eligible dependents effective on your date of hire
Employer-paid Short & Long-Term Disability, Basic Life Insurance and AD&D, (short-term disability buy-up available)
Paid Time Off
Employer retirement contribution and match after 1-year of eligible employment with a 3-year vesting period
Voluntary benefits include flexible spending accounts, legal plans, and life, pet, auto, home, long term care, and critical illness & accident insurance
Subsidized childcare at participating childcare centers
Tuition Reimbursement
Employee Assistance Program (EAP) support