Provider Enrollment Specialist - SSC

Job Description Summary

Responsible for all provider enrollment and re-enrollment activities of CMA d/b/a SSPAE.

Job Description

ESSENTIAL FUNCTIONS Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job's purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions that the person in the job is held accountable for. Following are the essential functions of the job. * Use this to denote if a function does not provide opportunity to perform beyond "Meets Expectations" 1. Provide oversight and facilitate enrollment activities to CMA d/b/a SSPAE and its 226+ providers for consistent insurance credentialing for all providers, which is inclusive of Physicians, Nurse Practitioners, Physician Assistants and Certified Nurse Midwives. a. Provider enrollment duties include initial payer credentialing, which consists of completion of confidential application information, obtain necessary signatures from providers, ensure appropriate paperwork and documentation is included with all applications. Submit to insurance payers for provider numbers as well as constant follow up on status on outstanding provider numbers, submitting any necessary paperwork. All information which is necessary to bill on the providers and CMA d/b/a SSPAE’s behalf. b. Develop data base of all provider insurance enrollment information. Develop practices to ensure Team members understand all the application requirements for each payer, including prerequisites, forms required, supporting documentation (DEA, CV etc.) and regulations. Work closely with provider recruitment and Medical Staff Services to expedite the completion of enrollment requirements. Work as an Intermediary with risk management for obtaining and requesting malpractice insurance for eligible clinicians to mitigate risk. Collaborate with the Medical Staff office or providers who provide independent malpractice insurance either through their primary employer or private practice. c. Work as a Liaison with Medical Staff office to maintain current provider information and licensure. d. Adjunct to billing company to ensure provider numbers and effective dates are entered into the system for timely turnaround on claim submissions. Also, works with the billing company on any claim issues that arise from insurance enrollment. e. Initial set up and maintenance of existing CAQH accounts for providers within CMA d/b/a SSPAE, which includes annual upload of current malpractice face sheets, quarterly re-attestation of CAQH account, and updating CAQH account and faxing of all current licensure, certifications and information as necessary or upon expiration. f. Maintaining current payer guidelines for 19+ specialties and provider types. 2. Works collaboratively with all departments, in particular the Medical Staff Office, Risk Management, SSPHO, Human Resources, the billing company (Ingenix) and those clinicians to achieve optimal results in reimbursement, communication, and overall operation of this activity. 3. Assures all regulatory requirements are met with Federal and State agencies and commercial payers. 4. Assists in the insurance enrollment processes which are vital to the flow of speedy enrollment, including CAQH, paperwork required from files obtained from the Medical Staff Office, mailing/faxing/scanning of paperwork for enrollment, maintaining spreadsheet of critical information on provider licensure and status on current, future and pending providers in process of enrollment. 6. ESSENTIAL FUNCTIONS (Cont.) I. Technology and Learning a. Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization. b. Embraces technological advances that allow us to communicate information effectively and efficiently based on role. NON-ESSENTIAL FUNCTIONS Non-essential functions are those tasks, duties and responsibilities that are not critical to the performance of the job. Following are non-essential functions of the job, along with the corresponding performance standards. 1. Transcribe dictated correspondences, and draft letters of general correspondence. 2. Distribute and update: periodic Matrix's to accommodate provider adjudication of all insurances including Medicare and Medicaid.