Provider Enrollment Specialist - CAP

Job Description:

Position Entity

Centralus Health

Position Title

Provider Enrollment Specialist

Position Code

Department

Cayuga Health Partners - Clinical Integration

Pay Range/Grade

FLSA Status

Non-Exempt

Position Type

Full Time

Remote Work Tier

Exposure Category

Reports To

CHP Director, Provider Enrollment

Centralus Health Mission

Our mission is to deliver high-quality care, empower our teams to success and improve the wellbeing of the communities we serve.

Job Summary

The Provider Enrollment Specialist is primarily responsible for the initial and ongoing maintenance of provider and organization data entry and enrollment needed to support multiple functions within the Cayuga Health Partners Network and Centralus Health. This positon will be responsible for completing provider enrollment applications according to internal policies, health plan policies, and other regulatory agencies such as NCQA, CMS, and NYS Department of Health, ensuring continued Network compliance. This position acts as a liaison between our Network, CHP providers and practices, and health plans. The Provider Enrollment Specialist will build and maintain professional relationships with Practice billing and credentialing staff, payer-provider representatives, and providers.

Job Functions

1. Perform provider enrollment activities as necessary.*
2. Manage the completion and submission of provider enrollment applications for CHP providers according to plan specifications. Understand specific application requirements for each payer including pre-requisites, forms required, form completion requirements, supporting documentation (DEA, CV, etc.) and regulations.*
3. Review and assess for completeness of information of enrollment documents, including current state licensure, liability insurance, DEA, etc.*
4. Responsible for follow-up with physicians and providers on missing information needed to complete payer enrollment.*
5. Responsible for the generating, mailing, tracking, and subsequent processing of provider revalidation applications. Interacts with representatives from health plans in an effort to resolve any delays in approvals as well as CHP Participants to answer inquiries and clarify requirements.*
6. Update Provider Data Management System when new information is received.*
7. Responsible for working with health plans on a routine basis to maintain their Provider Rosters.*
8. Responsible for notification to health plan and applicable CHP participants. Notification includes date of contract termination, anticipated health plan termination (if different than contract termination) and provider for membership re-assignment.*
9. Maintain a current and accurate Provider Roster, communicating provider changes to appropriate CHP staff to support Network Initiatives.*
10. Maintains extensive working knowledge of provider enrollment.*
11. Is flexible in assuming other appropriate responsibilities not noted above.

Important Note: (*) indicates an essential function of the job as defined by the Americans with Disabilities Act (ADA). Essential functions are the core duties that are fundamental to the position and must be performed, with or without reasonable accommodation.

Education / Experience Qualifications

Required:

• Education - Associate's degree
• Experience - Two to five (2-5) years of experience, including previous provider enrollment or credentialing experience with IPA / Medical Group / Hospital experience or healthcare operations experience (i.e. claims processing, billing, provider relations or contracting)
• Licensure - None required

Preferred:

• Notary Public certification preferred

Physical Requirements

• Hybrid position available. Preferred one to two days per week in the office as needed.
• 90% sitting; 10% standing

• Must be able to remain at a workstation and move around the workspace as needed to complete job tasks, with or without reasonable accommodation. This position may require occasional driving to practice locations.

• The person in this position frequently communicates with Practices and Providers. Must be able to exchange accurate information in these situations.