Job Description

Administrative/ Clerical


Phys Office Risk Management

Req Number:

Job Details:

Position Summary:

This Provider Enrollment Specialist is responsible for the timely enrollment of new physicians and on-going maintenance of existing providers. Enrollment includes but is not limited to managed care organizations and government payors such as Medicare, MA Medicaid and out of state Medicaid.


* Responsible for data entry of provider enrollment information into Provider Enrollment Database systems and distribution of information to designated department representatives and credentialing administrators.
* Accountable for all aspects of provider enrollment to ensure provider data is loaded appropriately in all relevant systems the first time. This includes understanding and communicating unique arrangements and ensuring the third party payors accurately credential the provider.
* Accountable for directly entering and updating provider data into the CAQH system.
* Follow-up with managed care organizations to ensure expedient credentialing.
* Accurately perform review of new enrollment files for deficiencies.
* Pursue incomplete information with practice contact or provider.
* Ensure third party payor provider enrollment is done in a timely and accurately in order to receive reimbursement.
* Responsible for the implementation and maintenance of provider and third party payor files within practice management software.
* Ensure that practice, provider and payor related tables are established and properly working.
* 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 and billing updates.
* Accountable for submitting termination requests to all health plans in a timely manner.
* Other duties as assigned.


* Associates degree required or equivalent combination of education and experience.
* National Association of Medical Staff Services (NAMSS) CPCS certification a plus.
* 3-5 years of working experience in a healthcare setting is required.
* Knowledge of provider credentialing and/or enrollment required.
* Knowledge of billing processes preferred.

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