Provider Enrollment Specialist Resume Samples

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MV
M VonRueden
Marcelle
VonRueden
27128 Lemke River
Detroit
MI
+1 (555) 777 3197
27128 Lemke River
Detroit
MI
Phone
p +1 (555) 777 3197
Experience Experience
02/2014 present
Houston, TX
Senior Provider Enrollment Specialist
Houston, TX
Senior Provider Enrollment Specialist
02/2014 present
Houston, TX
Senior Provider Enrollment Specialist
02/2014 present
  • Data entry of provider information within the provider enrollment applications and other supporting documents into the Medicaid Provider System
  • Works in conjunction with Provider Enrollment Specialist to resolve complex provider hold issues
  • Interfacing with providers to answer inquiries or gather further information regarding a provider’s enrollment via telephone and written correspondence
  • Prepares documents necessary for issuance of provider numbers for physicians and physician assistants associated with the billing service
  • Maintaining and updating the records of providers following the policies and procedures of NYS
  • Acts as a liaison to providers enrolling in the Medicaid program
  • Meets performance standards for accuracy, timeliness, and confidentiality
05/2009 12/2013
Los Angeles, CA
CSS Provider Enrollment Specialist
Los Angeles, CA
CSS Provider Enrollment Specialist
05/2009 12/2013
Los Angeles, CA
CSS Provider Enrollment Specialist
05/2009 12/2013
  • Provides management with regular updates on status of approval and claim resolution of each provider
  • Completes and obtains necessary documentation, malpractice application, signatures on payer applications, updates for all providers
  • Works with Athena to identify missing or inaccurate billing information
  • Ensures reappointment for hospital privileges and re-credentialing with payers are completed for all providers
  • Quantity - Meets performance and / or productivity standards
  • Attendance/Punctuality - Is consistently at work and on time
  • Professionalism - Approaches others in a tactful manner; Treats others with respect and consideration regardless of their status or position. Maintains positive business relationships
09/2004 01/2009
Boston, MA
Provider Enrollment Specialist
Boston, MA
Provider Enrollment Specialist
09/2004 01/2009
Boston, MA
Provider Enrollment Specialist
09/2004 01/2009
  • Works in the Provider Enrollment Unit and performs duties assigned
  • Develop and maintain relationships with Network Representatives in order to facilitate the provider enrollment/reenrollment processes
  • Make decision on provider enrollment applications based on the Virginia Medicaid program guidelines utilizing an automated enrollment workflow
  • Manage and maintain provider listings for Medicaid, Medicaid HMO and Private Insurance
  • Maintains all necessary provider number records in TeamWorks database
  • Assists in evaluation of reports, decisions, and results of Business Services in relation to established goals
  • Contact physician and non-physician providers to verify and correct any information on paperwork rejected from insurance companies
Education Education
Bachelor’s Degree in Professionalism
Bachelor’s Degree in Professionalism
University of Kentucky
Bachelor’s Degree in Professionalism
Skills Skills
  • Proficient in data analysis and knowledgeable of relational databases with demonstrated proficiency in report development using complex queries
  • Excellent organizational skills, detail oriented, ability to prioritize and multi-task and meet deadlines
  • Ability to maintain a professional attitude
  • Possess excellent verbal and written communication skills, including professional telephone skills
  • Demonstrates excellent communication skills and an ability to effectively prioritize work based on organizational and financial goals/impact
  • Ability to coordinate, analyze, observe, make decisions, and meet deadlines in a detail-oriented manner
  • Ability to learn new software programs quickly
  • Excellent attention to details
  • Good written and verbal communication skills, including professional telephone skills
  • Ability to access and retrieve information using a PC and basic understanding of Microsoft Office products
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11 Provider Enrollment Specialist resume templates

1

Provider Enrollment Specialist Resume Examples & Samples

  • Responds to telephone inquiries, emails and written correspondence using standard scripting, procedures and letters
  • Works in the Provider Enrollment Unit and performs duties assigned
  • Gathers information, researches/resolves inquiries and logs customer calls and correspondence
  • Communicates appropriate options for resolution in a timely manner
  • Effectively resolves assignments within specified timelines with attention to quality
  • Focus on providing excellent customer service in all aspects of contact with providers, recipients and clients
2

Provider Enrollment Specialist Resume Examples & Samples

  • Screen, track, report, process and complete incoming Medicaid provider enrollments
  • Screen, track, report, process and complete incoming Electronic Data Interchange (EDI) enrollments from providers, clearinghouses and vendor software companies
  • Returns incomplete enrollment or pends applications as appropriate
  • Coordinates the distribution of provider Welcome Letters and policy manuals
  • Screen, track, report, process and complete incoming provider file updates
  • Returns incomplete provider updates as appropriate
  • Ensures proper provider file maintenance
  • Follow and maintain the Enrollment and Update Operational Procedures
  • Prepare and respond to audit requests and inquiries
  • Communicates directly with call center agents, all internal departments, providers, potential providers, clearinghouses, software vendors, auditors, supervisors, managers, Office of Medicaid and State Agencies
  • Conducts enrollment and update training
  • Responds to questions from the Provider Relations Call Center phone agents regarding provider enrollment questions
  • Meet quality controls and production standards of the Provider Relations Department
  • Minimum three years customer service experience and excellent customer service skills
  • Strong organizational and communication (verbal and written) skills
  • Ability to meet or exceed deadlines
  • Ability to prioritize multiple tasks
  • Strong analytical, comprehension, and problem solving skills
  • Personal computer experience
  • Must be able to work independently and as a team member
  • Proficient keyboarding skills
  • Excellent attendance record
3

Senior Provider Enrollment Specialist Resume Examples & Samples

  • Data entry of provider information within the provider enrollment applications and other supporting documents into the Medicaid Provider System
  • Verifying entries made into the Medicaid Management Information Systems (MMIS) and other computer applications as needed
  • Ensuring the accurate and timely enrollment and maintenance of all Medicaid Provider Enrollment functions
  • Meets performance standards for accuracy, timeliness, and confidentiality
  • Acts as a liaison to providers enrolling in the Medicaid program
  • Other duties as assigned by Management. Education and Experience
  • Two years of healthcare experience
  • Ability to follow stringent instructions Special Requirements
  • Superior analytical and decision-making skills
  • Ability to multi-task in a fast paced environment All other duties as assigned
4

Provider Enrollment Specialist Resume Examples & Samples

  • Make decision on provider enrollment applications based on the Virginia Medicaid program guidelines utilizing an automated enrollment workflow
  • Screen existing and new providers utilizing state and federal database checks
  • Data enter provider demographics information accurately
  • Handle incoming phone calls and respond to inquiries regarding provider enrollment functions
  • 4 year college degree, preferred
  • A minimum of 1 year of related experience or experience in a healthcare field
5

Provider Enrollment Specialist Resume Examples & Samples

  • Timely completion and submission of credentialing/provider enrollment applications for all providers
  • Facilitation of state licensing, DEA registration, and liability insurance applications/renewals; and assurance of timely completion of reappointment/recredentialing forms
  • Serving as a liaison between the CSUs, hospital medical staff offices, and contracted third party payers in coordinating the credentialing /provider enrollment processes
  • Responsible for timely and accurate maintenance of information in the credentialing databases and resolution of system edits
  • Supporting and adhering to the U of M Physicians Compliance Program, including the Code of Ethics and Business Standards
6

Bwpo Provider Enrollment Specialist Resume Examples & Samples

  • Responsible for the ensuring timely enrollment of new providers with 3rd party payors; and maintenance of existing active physicians and advanced practice providers
  • Participate in training sessions and orientations with the 3rd party payors for provider enrollment staff throughout the BWPO, hospital and affiliates
  • Work closely with credentialing team to coordinate enrollment efforts and meet appropriate deadlines as a team
  • Follow BWPO policies and procedures as they relate to the provider enrollment process
  • Responsible for inputting provider enrollment information into MSO and Provider Enrollment Database systems; and distribution of information to designated department representatives and credentialing administrators
  • Need to keep current regarding any changes in managed care and other third party payor requirements for provider enrollment. Recommend changes in existing BWPO and hospital policies or procedures as necessary to comply with changes
  • Adhere to strict guidelines as established to assure payor and NCQA compliance. Participate in audits conducted by the agencies and payors to measure the BWPO compliance rate
  • Very strong organizational skills required to keep a very large and complex system running efficiently
  • Ability to identify problems in the licensing and enrollment process and strong problem solving skills needed to resolve any problem as they arise
  • Must have proven ability to maintain sensitive and confidential information
7

Provider Enrollment Specialist Resume Examples & Samples

  • Reviewing provider enrollment applications and other documents for completeness
  • Maintaining and updating the records of providers following the policies and procedures of NYS
  • Interfacing with providers to answer inquiries or gather further information regarding a provider’s enrollment via telephone and written correspondence
  • Acts courteously and effectively with all stakeholders within the community
  • Other duties as assigned by Management
  • Ability to follow stringent instructions
8

Provider Enrollment Specialist Resume Examples & Samples

  • Responsible for ensuring the timely enrollment of new providers with the governmental payors including but not limited to Medicare, MA Medicaid, and out of state Medicaid
  • Accountable for overseeing and for directly updating provider data in the CAQH system, as necessary
  • Responsible for the on-going maintenance of existing providers including but not limited the submission of maintenance forms to update personal and practice demographic data for providers, billing updates, et al
  • Accountable for submitting termination requests to all health plans in a timely manner
  • Produce weekly enrollment reports
  • Acts as liaison to BWPO and hospital departments, outside agencies, physicians, medical practice groups, etc
  • Performs other duties as required or directed
  • Associates degree required. Bachelor’s degree preferred. In lieu of degree, will consider individual with directly related experience in provider enrollment and/or credentialing in health care setting
  • CPCS certification a plus
  • Requires 1 - 3 years experience in a healthcare setting
  • Knowledge of managed care or provider credentialing required
  • Knowledge of billing processes preferred
  • Ability to work well with all levels of personnel
  • Skilled in basic computer programs, such as Word, Excel, and Access. Experience with Microsoft Office
  • Promotes and maintains a professional demeanor both personally and for the Hospital
  • Able to function independently and perform routine department procedures without supervision
9

CSS Provider Enrollment Specialist Resume Examples & Samples

  • Ensures providers are appropriately credentialed to guarantee no loss of revenue for the system
  • Completes and obtains necessary documentation, malpractice application, signatures on payer applications, updates for all providers
  • Researches and resolves claim issues with payers to ensure appropriate revenue capture
  • Provides management with regular updates on status of approval and claim resolution of each provider
  • Work with practice operational leadership to resolve issues regarding provider enrollment issues and concerns, maintain appropriate documentation for each provider with each payer
  • Works with Athena to identify missing or inaccurate billing information
  • Ensures reappointment for hospital privileges and re-credentialing with payers are completed for all providers
  • Responsible for CAQH files for providers to ensure completion and maintain revisions/updates
  • Responsible for creating and maintaining NPI registry information
  • Maintains and optimizes use of credentialing software or credentialing tracking tools
  • Exhibits strong communication skills and positive attitude
  • Performs all other duties per position description and as assigned
  • Ability to interact positively in a team environment, demonstrating superior teamwork skills
10

Provider Enrollment Specialist Resume Examples & Samples

  • Associate degree with one year of credentialing experience or three plus years of credentialing/enrollment experience in lieu of Associate degree required
  • Two years of experience in a healthcare business office or third party payer setting with technical knowledge of regulatory requirements for credentialing and privileging
  • Working knowledge of office products and credentialing/ enrollment software required
  • Critical thinking and data analysis skills
  • Ability to craft correspondence clearly taking into consideration the audience knowledge
  • Intra-personal and team-building skills; excellent verbal and written communication skills; ability to problem solve and resolve conflicts; demonstrated organizational and time management skills
  • Proven respect for confidentiality and attention to detail
11

Provider Enrollment Specialist Resume Examples & Samples

  • Provide functional support to the Provider Enrollment Support Team within the Operations Support Department
  • Prioritize tasks and facilitate operations support activities based on TIN management needs, regulatory changes, and/or mergers and acquisitions
  • Completes physician, nurse practitioner, and physician assistant applications to enroll/dis-enroll providers with payers and to modify provider data with payers
  • Performs follow-up with insurance payers via phone, email or website to obtain billing numbers and resolve provider enrollment issues
  • Forward applicable provider billing numbers to the appropriate Billing Service Center(s)
  • Update TeamWorks provider database as needed
  • Follow TeamHealth policies, procedures, and protocols in order to ensure accuracy, completeness, and efficiency of provider enrollment processes
  • Perform other duties as assigned (this may include tasks in regional service centers)
  • Two (2) years of college required; bachelor’s degree preferred
  • Three (3) to five (5) years of experience in a provider enrollment or credentials position
  • Ability to work with minimal direct supervision
  • Ability to collaborate with internal and external resources and be able to meet deadlines
  • Ability to adapt to flexible work schedules and frequent interruptions
  • Ability to problem solve, make decisions, and effectively communicate decisions Excellent time management skills
  • Data entry accuracy
  • Proficient computer skills (word-processing, spreadsheet, database management)
12

Provider Enrollment Specialist Resume Examples & Samples

  • Participate in establishing new pediatric, anesthesia and pain management practices. Set up new entity and obtain group provider numbers for entity and providers
  • Obtain required credentialing paperwork from insurance companies. Complete paperwork with required information from existing credentialing files and/or in conjunction with the physician or non-physician provider
  • Upon completion of paperwork and after ensuring propriety, forward paperwork to insurance companies to be assigned the necessary provider identification numbers
  • Work with new physician and non-physician providers to ensure the necessary documentation is completed, returned, and forwarded to insurance companies so that claims processing and cash flow delays are prevented or minimized
  • Field telephone or written inquiries, questions and concerns from insurance companies and physician or non-physician providers regarding the status of provider identification numbers or credentials in a clear, concise and courteous manner
  • Maintain organized and accurate files as well as an efficient and effective credentialing tracking system to ensure the credentialing is obtained from all physician and non-physician providers. Ensure that all insurance companies have current and accurate information they need to process claims in a timely manner
  • Notify and keep informed the appropriate team and Hospital(s) personnel/department(s) of credentialing information obtained, in process or pending regarding physician and non-physician provider numbers
  • Keep Billing Services and Systems Supervisor informed at all times of the status of new/revised or pending physician and non-physician provider numbers, effective dates, plans, etc. to prevent delayed claims filing and cash flows
  • Maintains understanding and apply North Carolina Quality Assurance credentialing standards
  • Maintains highest level in integrity and compliance with MEDNAX Services, Inc.corporate HIPAA and Confidentiality policies pertaining to sensitive, confidential physician and non-physician provider or patient information
  • As time permits, will assist with other support functions such as, assisting with claims processing, and support departments to resolve errors or submission problems
  • Manages or participates on special projects as assigned and maintain individual productivity and performance standards
  • Communicate credentialing issues to supervisor or other management personnel and make recommendations regarding changes to credentialing processes
  • Assists in evaluation of reports, decisions, and results of Business Services in relation to established goals
  • Recommends new approaches, policies, and procedures to effect continual improvements in efficiency of Business Services and services performed
  • May serve as a member of the Management Team or New Practice Acquisition Teams representing Provider Enrollment. Performs duties necessary to ensure the team’s projects/goals are completed. Takes ownership of special projects, researches data and follows through with detailed action plans. Actively participates in problem identification and resolution and coordinates resolutions between appropriate parties
  • Associate Degree in Business with four years of progressive physician billing and credentialing experience or Bachelor Degree in business with three years of progressive physician billing and credentialing experience preferred
  • Excellent customer service skills and communication skills, both written and verbal
  • Ability to manipulate large volumes of data using database management software
  • Ability to organize, prioritize and schedule work assignments
  • Ability to manage multiple projects with competing demands
13

Provider Enrollment Specialist Resume Examples & Samples

  • Prepare documents necessary for issuance of provider numbers for physicians and physician assistants
  • Maintains deletions, additions, and changes to the physician maintenance file pertaining to physicians and to other pertinent information including quarterly review of group membership
  • Handles telephone communication and written correspondence with providers, and fiscal intermediaries in an efficient and effective manner that facilitates the Provider Enrollment process
  • Maintains updated information on carrier requirements through contact with the carriers and by reviewing carrier bulletins, and other materials sent to the providers and from the Supervisor
  • Works in a team effort on projects such as new start-ups for renewal, re-credentialing group applications as required by carriers by business changes such as Tax ID numbers and entities, or when directed by the Supervisor
  • Reports any problems, errors, and/or changes detected in provider enrollment requirements when discovered
  • Prepares documents in a consistent and accurate manner
  • Communicates information to input into the IDX System including new providers and updates of provider information using the appropriate forms
  • Responsible for working weekly DMS issues
  • Responsible for working provider hold
  • Follows Team Health guidelines for preparing documents in a consistent and accurate manner
  • Understands and complies with Team Health Compliance Program
  • Minimum of 45-50 WPM typing skills
  • Persuasive sales ability
  • Good decision-making and problem-solving skills
  • One year of experience in a business setting with fundamental clerical skills, preferably with medical or provider enrollment background
  • Possesses previous experience with health care billing and medical reimbursement
14

Provider Enrollment Specialist Resume Examples & Samples

  • Prepares provider applications for third party payers
  • Coordinates correspondence to carriers and billing agent to expedite provider number assignments
  • Coordinates delivering provider applications to appropriate health plans. Includes adherence to strict deadlines and procedures
  • Performs follow-up with health plans in order to expedite participation approval by each health plan
  • Maintains systems to identify and disseminate to others regarding status of health plan participation
  • Troubleshoots miscellaneous provider enrollment-related information requests, billing issues indicated on provider hold report and requests arriving from insurance plans or billing agent
  • Interacts with TeamHealth colleagues to stay current on third party payer issues and topics
  • Coordinates with insurance carriers to maintain most current application and processes for enrollment
  • Resolve issues between carrier and billing agent that do not require provider intervention
  • Coordinates, completes, and follows-up on the revalidation process for contracted payers
  • Insures current information is on file for all contracted physicians and all pertinent documentation is forwarded to appropriate third party payers
  • Maintains personal adherence to professional confidentiality standards established within the Department and in accordance with legal, ethical, payor organization practices and hospital policies
  • Other duties as assigned for enrollment
  • Participates in an integrated work team as a responsible team member
  • Assists in the facilitation of the team processes within Provider Enrollment. This includes attending all team related meetings; participating in developing, implementing and achieving team goals; participating in problem-solving and decision making; supporting corporate and regional management decisions; being flexible and adaptable to change; establishing trust and respect for other team members; placing team needs first; and by completing all necessary training
  • Follows the norms and guidelines established by the team for communication, production, efficiency, conflict resolution, decision-making, problem-solving, and interpersonal relations
  • Maintains all necessary provider number records in TeamWorks database
  • Independently problem solves and utilizes resources to obtain information when needed
  • Two years of college preferred
  • One to three years of medical terminology experience or medical background preferred
  • One to three years of Provider Enrollment or Credentialing experience required
  • Previous medical billing desired
  • Ability to handle multiple tasks and assignments
  • Excellent oral communication and presentation skills
  • Ability to work with confidential information and use discretion
  • Ability to coordinate and meet deadlines and deal with stressful situations
  • Ability to problem solve and make decisions
  • Ability to work productively within a team
15

Senior Provider Enrollment Specialist Resume Examples & Samples

  • Prepares documents necessary for issuance of provider numbers for physicians and physician assistants associated with the billing service
  • Maintains deletions, additions, and changes to the physician maintenance file pertaining to physicians and to other pertinent information including periodic review of group membership
  • Establishes and maintains detailed provider relations application process (including sample applications), specific state requirements, with name, address, and phone number of the contact people at each intermediary for assigned areas. The Senior Provider Enrollment Specialist is to be proficient in creating provider applications
  • Works independently with telephone communication and written correspondence with provider and fiscal intermediaries in an efficient and effective manner that facilitates the provider enrollment process
  • Works in conjunction with Provider Enrollment Specialist to resolve complex provider hold issues
  • Reports any detected problems, errors, and/or changes in provider enrollment requirements when discovered
  • Maintains updated information on carrier requirements through contact with the carriers and by reviewing carrier bulletins available Internet information, and other materials sent to the providers and from the Supervisor
  • Works on projects such as new start-ups for renewal, re-credentialing group applications as required by carriers by business changes such as Tax ID numbers and entities, or when directed by the Supervisor
  • Works independently to oversee the team workers in Provider Enrollment follow-up system to ensure that the provider application process is managed in an efficient and effective manner for all assigned Billing Centers
  • Prepares reports and interacts with the A/R group and other components of the billing service to facilitate problem solving and communication. As well as, researching and resolving denials that is sent to you through the Denial Management System
  • Meticulous accuracy
  • Works independently with a minimum of supervision
  • Good independent decision-making and problem-solving skills
  • Three years of experience in a healthcare or medical office setting with fundamental clerical skills, preferably with provider enrollment background
  • Possesses previous experience with health care billing and medical reimbursement processes
16

Provider Enrollment Specialist Resume Examples & Samples

  • Operational support for Provider Enrollment functional area
  • Generate, track and follow up on group and/or provider applications to government and commercial payers, as applicable to each line of business
  • Serve as liaison between service center provider enrollment leaders, Operations Support and National Provider Enrollment Departments
  • Assist with operations support activities as assigned by the National Director, Provider Enrollment, based on service center needs, division start-ups, regulatory changes, and/or mergers and acquisitions
  • Follow TeamHealth policies, procedures, and protocols in order to ensure accuracy, completeness, and efficiency of provider enrollment processe
  • Participate in monthly provider enrollment task force calls, providing input and publishing meeting minutes
  • Provide back office operations support during mergers and acquisitions, pre- and post-acquisition, to include integration and TeamWorks implementation
  • Two (2) years of college (Bachelor’s degree, preferably)
  • Proficient to advanced level computer skills (spreadsheet, word-processing, database management)
  • Ability to problem solve, make decisions, and effectively communicate outcome
  • Ability to work in a fast paced environment where priorities tend to change often
  • Ability to handle confidential information and discussions
  • Excellent organizational skills and
  • Strong analytical skills and attention to detail, including understanding of how to interpret operational processes and translate them into documented processes and requirements
17

Provider Enrollment Specialist Resume Examples & Samples

  • Typically, 1-2 years of working experience in related fields
  • Ability to follow written policies and procedures
  • Ability to access and retrieve information using a PC and basic understanding of Microsoft Office products
  • Ability to follow procedural guidelines.'
  • Good written and verbal communication skills, including professional telephone skills
18

Provider Enrollment Specialist Resume Examples & Samples

  • Completes provider payer enrollment/credentialing and recredentialing with all identified payers in a timely manner
  • Handles highly sensitive and confidential information regarding professional providers
  • Resolves enrollment issues through collaboration with physicians, non-physicians, office staff, management, contracting, insurers and others as identified
  • Maintains positive working relationships with providers
  • Plays an active role in explaining and informing providers and practice/office managers of the submission requirements for credentialing/recredentialing processes, stressing the importance of compliance with these processes
  • Obtains updated provider information from various sources including provider offices, state licensing boards, malpractice insurance companies, residency training programs, etc. Identifies and resolves problems with primary source verification elements by interpreting, analyzing and researching data
  • Proactively obtains updated provider credentialing data prior to expiration
  • Creates, develops, and maintains applicable matrices and/or utilizes departmental software that supports the enrollment functions
  • Completes all additions, updates and deletions. Supports new provider onboarding processes as related to enrollment
  • Provides updates to on-site practice management staff and others with any changes to requirements for credentialing individual providers based on government and commercial payer credentialing processes
  • Proactively communicates any changes regarding contracting as it relates to enrollment and operations
  • Communicates updated payer enrollment information including payer provider numbers to practice operations in a timely manner while fostering positive working relationships and team work with departments, vendors, etc
  • Develops databases and spreadsheets for tracking organizational providers
  • Ensures data is accessible/transparent for executive inquiries or other information as deemed necessary by management
  • Continuously searches for process improvements to achieve accuracy and efficiencies
19

Provider Enrollment Specialist Resume Examples & Samples

  • Manage and track all Medicaid / Private Insurance billing provider enrollment application agreements by electronic and/or by paper and ensure all agreements are keep up to date
  • Ensure all billing related provider enrollment application agreements include initial enrollments, changes and updates
  • Communicate with internal and external customers including but not limited to medical and operational crew members to gather appropriate information and report any pended information to internal leadership
  • Manage and maintain provider listings for Medicaid, Medicaid HMO and Private Insurance
  • Compile and maintain standardized company documents/attachments as appropriate
  • Manage up-to-date knowledge of various PPO, HMO, Medicare, Medicaid and other payer reimbursement structures
  • Associate’s degree (A.A.) or equivalent from two-year college or technical school; and one to three years’ experience in complex healthcare contract/agreements and/or training; or equivalent combination of education and experience
  • Experience in handling various aspects of billing, data integrity and collection function for a healthcare provider preferred
  • Knowledge of various PPO, HMO, Medicare, Medicaid and other payer reimbursement structures
  • Knowledge and understanding of claim process
  • Proficient in data analysis and knowledgeable of relational databases with demonstrated proficiency in report development using complex queries
  • Excellent organizational skills, detail oriented, ability to prioritize and multi-task and meet deadlines
  • Advanced customer service and phone skills
  • Intermediate Microsoft Office Suite, including Word, Excel, Access and Outlook
20

Provider Enrollment Specialist Resume Examples & Samples

  • Prepare and submit provider enrollment applications to various carriers
  • Will act as a liaison between dentists and insurance carriers
  • Perform other clerical and administrative responsibilities as assigned
  • High School Diploma or equivalent required, College Degree preferred
  • Excellent verbal & written communications & customer service skills
  • Excellent time management and prioritization skills a must
  • Working knowledge of various Payor categories (PPO, DHMO, Indemnity, etc.) preferred
21

Provider Enrollment Specialist Resume Examples & Samples

  • Accurately complete the enrollment/reenrollment processes as outlined by each network/area for all appropriate healthcare providers as identified through department policies and network reimbursement and delegated contracts to ensure timely and continued provider network participation
  • Maintain detailed provider enrollment files in electronic format, including electronically received documents and scanning of hardcopy documents, and document each stage of enrollment/reenrollment process thoroughly
  • Accurately maintain all internal systems with appropriate provider and network participation information. Systems including, but not limited to, Epic, Echo, Excel, Remedy PE Tracker, IGUIDE, and the Managed Care Manual
  • Develop and maintain good working relationships with Nemours providers and support staff to obtain necessary and timely information to facilitate the provider enrollment/reenrollment process
  • Develop and maintain relationships with Network Representatives in order to facilitate the provider enrollment/reenrollment processes
  • Responds to and resolves problems with provider network participation as it relates to denial of services or reimbursement by working closely with all levels of administrative and clinical personnel and network representatives
  • Responsible for educating providers, administrators and support staff regarding the enrollment/reenrollment processes and how it relates to the provider's ability to provide care to network members in order to increases reimbursement and reduce patient dissatisfaction
  • Work collaboratively with fellow team members to create, evaluate and maintain department workflows, processes, policies and systems. Additionally, each team member is expected to cross train on location and provider type requirements to assist one another in completing assigned duties as the enrollment cycle warrants
22

Provider Enrollment Specialist Resume Examples & Samples

  • Establishes, maintains, and constantly reviews the accuracy of Medicare, Medicaid, CSHCN, Texas Health Steps, and Railroad Medicare provider billing numbers for providers. Ensures that the numbers are (a) correct, (b) attached to the appropriate provider address, (c) grouped in the appropriate provider groups, (d) communicated to the appropriate CPG staff for billing and collection purposes, and updated in cases where a provider either moves locations, changes billing organizations or leaves employment/agreement. Maintains observation of provider commercial enrollment. Completes this process for both new and existing providers
  • Develops and maintains extraordinary expertise on CPG Medical Practice Management (MPM) system and Provider Profile Database. Responsible for MPM Master File and provider database maintenance which will predominantly include completeness and accuracy of data to ensure clean claim submissions as it pertains to provider billing numbers. Responsible for monitoring and correcting/clearing all enrollment related claim issues in MPM system. Maintains documentation of any and all updates and changes to these files, ensuring the integrity of data by following established CPG processes
  • Routinely communicates with both CPG Revenue Cycle, CPG outside billing agents, Ark-La-TX Health Network, and CPG Managed Care Department to scan for billing and collection issues related to provider numbers. Confirms accuracy of issues and then initiate's corrective action to ensure proper flow of billing and collection information to third party payers. Documents all interaction with parties outside CPG in order to track the efficiency and effectiveness of contact, date, content of interaction, commitment by outside party or action and by what date, and then confirmation that such action was taken and taken correctly
  • Serves as a resource to staff to problem solve and answer questions regarding programs and procedures. In this capacity, establishes excellent customer service skill set
  • Perform other related work duties as required
  • Requires minimum of five years' experience within the medical practice management field with emphasis on billing and collection processes
  • Proficiency with Microsoft (Word, Excel, Access, Outlook) applications required
  • Knowledge of physician billing specific to Medicare and Medicaid plans required
  • Knowledge of Medicare, Medicaid and other managed care plan enrollment processes preferred
  • Career accomplishments must demonstrate a capacity to work continuously at a highly detailed level and the ability to meticulously follow-up on and document work assignments
  • Candidate must demonstrate a high level of desire for completeness, accuracy and critical thinking
23

Provider Enrollment Specialist Resume Examples & Samples

  • Generate Applications Sent to Carrier but not Effective' reports from Teamworks
  • Follow up with carriers and document in Teamworks
  • Receives notification of provider number/effective date and PAR status(es)
  • Completes, submits and documents stationery to billing center
  • Works with corporate hold report, releases claims, identifies charge corrections and write offs (write offs must have approval of PE Director)
  • Resolves DMS issues each week by researching and releasing claims, solving enrollment issues with payers and/or ensuring revalidation is complete
  • Review weekly exception reports from management to prioritize critical issues
  • Resolve deficiencies
  • Delegates revalidations and re-enrollment to Provider Enrollment Coordinator when identified
  • Research and reviews billing center inquiries about IDX and billing issues
  • Train staff on Provider Enrollment processes
  • Support Provider Enrollment Department
  • HS Diploma or equivalent; Some college preferred
  • One year of experience with contracts, legal documents or other health care related work
  • Excellent communication skills (verbal and written); Ability to communicate effectively with Providers, Medical Directors and VPOs
  • Excellent organizational skills with the ability to prioritize and manage multiple projects
  • Ability to meet challenging deadlines; ability to function in stressful situations
  • Overtime may be required; Some training and seminar attendance may require overnight travel
24

Provider Enrollment Specialist Resume Examples & Samples

  • Complete the individual provider enrollment with Allina contracted payers (both commercial and government)
  • Research and understand the Out of State Medicaid requirements for enrolling the Allina Health Providers, if applicable
  • Participate in payer specific workgroups and provide individual enrollment expertise on payer requirements including Medicare and MA
  • Complete appropriate steps for updating and maintaining Provider Enrollment Databases and to ensure claims processed timely and accurately. Handle the recredentialing process for individual providers. Request and update expireables for individual providers
  • Ensure all work is performed according to established policies and guidelines. Frequent provider interaction to ensure timely 3rd party payer enrollment is completed
  • Receive and initiate calls to 3rd party payers, answer an ACD call system, respond to internal and external customer questions and requests for proper resolution
25

Provider Enrollment Specialist Resume Examples & Samples

  • Demonstrates an in-depth understanding of CMS and commercial payer enrollment rules regulations
  • Maintains current knowledge of CMS and commercial payer enrollment rules and regulations, and serves as an resource across the organization
  • Works in collaboration with various departments and individuals throughout the organization in all phases of the provider enrollment and re-enrollment process to ensure accurate completion and timely submission of all contracted payer enrollment forms and notifications, including Medicare 855 forms
  • Responsible for requesting and maintaining all organizational and individual NPI numbers
  • Provides support as needed to the Medical Staff Office to ensure accurate and timely submission of all delegated enrollment requests
  • Responsible to perform follow up with delegated payers to verify effective date information and confirm requests are processed accurately and timely
  • Demonstrates ability to create and maintain a complex system of records, including but not limited to the enrollment tracking spreadsheet and NPI enumeration spreadsheet
  • Monitors status of pending enrollment submissions until approval notification/assigned billing number is received
  • Communicates approvals/billing number assignment information to billing office(s) in a timely manner to allow for optimal A/R and financial performance
  • Demonstrates self-motivation with the ability to work independently, effectively prioritize work based on operational and financial goals/impact, and make appropriate decisions within the scope of the position
  • Participates effectively as a team member, specifically with Physician Employment Services, CredentiaSource, Medical Staff Services, Payer Strategy, Facility and Physician Billing Offices
  • Minimum of three (3) years of hospital or physician billing, physician practice or hospital business office experience, required
  • Two year degree in business or related healthcare field, preferred
  • Prior provider enrollment experience, preferred
  • Demonstrates excellent communication skills and an ability to effectively prioritize work based on organizational and financial goals/impact
26

Provider Enrollment Specialist Resume Examples & Samples

  • Bachelor's Degree in Healthcare Administration or similar field preferred or a minimum of 1 year of provider enrollment experience
  • Working knowledge of Microsoft Office products, particularly Excel and Word
  • Ability to work independently with some supervision
  • Team player, strong analytical skills and ability to problem solve, strong organizational skills, strong interpersonal communication skills, and demonstrated work ethic
27

Provider Enrollment Specialist Resume Examples & Samples

  • Bachelor degree in related area and / or equivalent experience / training
  • Minimum three years related experience
  • Working knowledge of Credentialing processes and required medical licensure for valid provider enrollment with governmental agency
  • Thorough knowledge of data management and documentation methods used in provider enrollment
  • Solid skills to evaluate issues and identify solutions. Demonstrated ability to solve problems and suggest solutions through critical thinking process
  • Proven ability to apply external regulatory guidelines and internal accounting and administrative policies knowledge and skills to assess and monitor compliance and effectiveness of processes
  • Excellent time management skills and ability to independently set and meet deadlines while multi-tasking and assigning precedence to competing priorities. Ability to see multiple assignments through to completion on deadline
  • Demonstrated excellent written and verbal communications skills, with the ability to interpret and convey complex clinical finance information in a clear, concise manner. Ability to summarize and present reports and presentations
  • Demonstrated analytical and problem-solving skills, with the ability to evaluate the effectiveness of workflows and systems
  • Demonstrated interpersonal skills to work effectively in a team environment with internal staff in a wide variety of business and clinical areas. Skills to work collaboratively, coordinate and integrate with others throughout the department, hospital and campus. Ability to communicate through all mediums and with all groups and work under pressure of constantly changing deadlines and priorities
28

Provider Enrollment Specialist Resume Examples & Samples

  • Manage the successful completion and submission of provider enrollment applications
  • Perform tracking and follow-up to ensure providers are established and linked to the appropriate EMHS group entity in a timely manner
  • Understand specific application requirements for each payer including pre-requisites, forms required, form completion requirements, supporting documentation and regulations
  • Maintain documentation and reporting regarding provider enrollments in process
  • Maintain provider enrollment files electronically via EMHS credentialing software, shared computer files and CAQH (Council for Affordable Quality Healthcare)
  • Work closely with departments credentialing staff and member hospitals to expedite completion of forms and requirements including obtaining signatures, locating required documentation, etc
  • Ensure that established provider IDs and effective dates are communicated to appropriate billing and revenue departments so claims can be processed for submission
  • Maintain provider enrollment information within the EMHS credentialing database
  • Establish close working relationships within department and with various departments across system
  • Process and distribute appropriate correspondence
  • Maintain working knowledge of applicable regulations, policies and procedures
  • Represent the office to internal and external customers as appropriate
  • Perform miscellaneous job-related duties as assigned
  • Associates degree or high school diploma/equivalent with at least 2 years of medical office experience
  • General understanding of the medical staff organization and Joint Commission/Healthcare Facilities Accreditation Program/National Committee for Quality Assurance standards. State/federal/licensure regulations, particularly as it relates to the provider enrollment
  • Experience with Microsoft Office products, including but not limited to Excel and Outlook
  • NAMSS Certification as a Certified Provider Credentials Specialist (CPCS) or Certified Professional Medical Services Manager (CPMSM)
  • NAMSS Certification as either Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS)
  • Affiliation and participation with the Maine Association Medical Staff Services
  • Ability to research and analyze documents
  • Ability to work independently, set priorities and meet deadlines with minimal supervision
  • Strong working knowledge of word processing, spreadsheets, data entry, data base experience and other computer related skills. Experience with other Microsoft Office products and HealthLine
  • Systems ECHO credentialing software preferred
  • Must be able to communicate well with a wide variety of contacts at all levels of the organization
  • Must be able to work cohesively in a team oriented environment and be able to foster good working relationships with others both within and outside the organization
  • Ability to maintain confidentiality, work with deadlines and manage multiple priorities
  • Ability to maintain a high degree of professionalism and independent judgment in response to complex sensitive issues and decision-making
  • Ability to understand contracting and billing practices relating to EMHS provider enrollment
29

Provider Enrollment Specialist Resume Examples & Samples

  • Enroll/re-enroll all eligible providers under which services will be billed, such as MDs, DOs, PhDs, PAs, ARNPs, CRNAs, etc
  • Prepare and distribute enrollment packets for each eligible provider for all applicable carriers
  • Obtain UFJP provider number from Accounting upon receipt of initial carrier authorization for each eligible provider
  • Maintain PC database of Provider enrollment information
  • Verify physician hospital privileges at all appropriate hospitals
  • Verify provider employment start dates with the Office of the Dean
  • Follow-up on all open provider enrollment applications with carriers through issuance of provider numbers
  • Maintain records of provider enrollment and certification documentation
  • Interact with Information Services to insure timely updates of provider information, including but not limited to: UFJP provider number, billing locations, and carrier provider numbers in the IDX system provider dictionary
  • Periodically maintain and distribute a complete provider directory, identifying providers and provider departments, divisions, locations, numbers, status, and approved carriers
  • Distribute provider start and termination date information to all appropriate personnel
  • Assist providers, clinic personnel and co-workers with enrollment issues and questions
  • Inform appropriate personnel and providers of changes in key enrollment issues/policies
  • Assist Director of Education, Reimbursement and Analysis with research and analysis for special projects as assigned
30

Provider Enrollment Specialist Resume Examples & Samples

  • Ability to work in a production environment under strict quality and production requirements
  • Possess excellent verbal and written communication skills, including professional telephone skills
  • Ability to analyze, identify, and resolve issues
  • Ability to project a positive attitude and a high degree of self-confidence
  • Knowledge of Medicaid billing a plus
31

Provider Enrollment Specialist Resume Examples & Samples

  • Electronically review assigned faxes and emails daily
  • Receive assigned mail relating to provider enrollment daily and turn electronic
  • Process assigned provider enrollment documents daily
  • Re-direct non-credentialing documents daily
  • Stamp all enrollment documents assigned daily
  • Conduct review of assigned provider enrollment documents daily
  • Research for active records in enterprise system
  • Enter or update existing provider records in enterprise system
  • Work with providers by phone, fax, U.S. mail, and email to ensure that they complete the enrollment process
  • Follow up with providers to ensure that all necessary information is received and that the enrollment process is completed timely
  • Develop relationships with providers and their staff and answer questions they may have about the process
  • Coordinate scanning of documents and store electronically to Cactus credentialing software
  • Track daily intake volumes
  • Audit provider contract effective dates for execution
  • Coordinate contract execution
  • Scan provider contracts
  • Electronically file provider contracts
  • Research and correct data to avoid duplicate provider, locations or payees
  • High School diploma or equivalent, Associate’s degree preferred
  • 1-3 years of experience in business environment
  • Proficient in the use of Excel
  • Proficient in general computer software (Word, Outlook, Powerpoint)
  • Proficiency in the use of Cactus credentialing software preferred
  • Ability to learn new software programs quickly
  • Ability to create status reports on metrics
  • Ability to analyze data to determine next steps
  • Experience in credentialing preferred