Provider Enrollment Specialist

Under the direct supervision of the Provider Enrollment Supervisor, the Provider Enrollment Specialist is responsible for maintaining both participating and non-participating provider records in the provider database, mapping claims in the invalid provider queue, resolving provider related issues for claims suspended to Provider Enrollment. Executes the panel transfer process. Completes projects as assigned by Supervisor. Interacts with internal/external clients on provider maintenance activities.

• Communicates notification of changes to appropriate providers, members and other departments within the contracted time frame.
• Coordinates the provider mailing for all claims in the invalid provider queue that could not be processed due to missing or invalid information.
• Researches and resolves returned checks and provider mail.
• Assists provider and internal customer by responding to and resolving all request and inquiries related to the Panel Transfers, Panel Releases, & Special Needs PCP assignments process.
• Completes department reports and logs as assigned.
• Ensures that work is completed according to service level agreements.
• Attends required training on an annual basis.

Knowledge of different types of providers, claims process exp preferred.
Customer service exp required.
Software systems including Windows 2000, MS Office, IMAX (external Claims editing),
Facets preferred.
Knowledge of Word, Excel, and ACCESS is a plus.
1-3 Years of Healthcare Experience
Minimum 4 years exp in claims and/or call center

Required

• CLAIMS
• EXCEL
• FACETS
• SERVICE LEVEL AGREEMENTS
• MS OFFICE

Additional

• RETAIL SALES
• MICROSOFT WINDOWS
• QUEUE MANAGEMENT
• DATABASE
• MICROSOFT OFFICE
• MAINTENANCE
• CUSTOMER SERVICE ORIENTED
• TOPO