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Role Description

The Provider Enrollment Representative is responsible for accurate set up of provider records in order to assure proper payment for providers. They also handle all implementation steps to enroll providers in the Plan to ensure timely access for members and accurate payment for providers.

Key Functions/Responsibilities

• Accurately complete the enrollment/re-enrollment processes of providers as identified through department policies, network reimbursement, and delegated contracts.
• Maintain detailed provider enrollment files in electronic format, including electronically received documents and scanning of hard copy documents.
• Proactively initiate oversight of existing provider record issues/problems and coordinate resolution of issues identified by external stakeholders and/or providers.
• Coordinate updates and communication between provider(s) and appropriate stakeholders, including follow-up communications and issue resolution.
• Adhere to policies and procedures including data security and HIPAA requirements.
• Utilize the Onyx database, optimizing efficiency, and perform document generation.
• Acquire and demonstrate thorough knowledge of contractual arrangements and payment methodologies.
• Ensure the quality, completeness, and accuracy of provider data for compliance with Medicare and Medicaid regulations and guidelines.
• Work closely with the credentialing team to coordinate enrollment efforts and meet appropriate deadlines.
• Independently initiate oversight of existing provider record problems and facilitate resolution.
• Coordinate set up and hand off of provider records to the Credentialing Department.
• Review submitted applications and supporting documentation for compliance with NCQA and applicable state requirements.
• Follow established contracting process to ensure smooth implementation of provider contracts.
• Research, facilitate, and assist with resolution of interdepartmental issues related to enrollment.
• Maintain the integrity of Provider Data in Onyx and assist with ongoing quality initiatives.
• Provide system analysis support as needed to ensure operational compliance with Plan provider and database rules.
• Other duties as assigned by manager.

Qualifications

• Bachelor’s degree or an equivalent combination of education, training, and experience is required.
• 2 or more years of business experience in a managed care or healthcare setting is required.
• Ability to work as a team member, manage multiple tasks, be flexible, and work independently.
• Excellent organizational and problem-solving skills.
• Ability to accurately enter, proof, submit data, and identify inaccurate data and process to resolution.
• Demonstrated competence using Microsoft Office products, especially Word, Excel, Outlook, Access, PowerPoint.
• Experience or knowledge of ONYX, FACETS, and/or similar provider data and/or claims processing systems.
• Effective communication skills (verbal and written).

Requirements

• Ability to work OT during peak periods.

Compensation Range

$20.19 - $29.33. This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, considering factors such as education, experience, skills, and certifications/licensure.

Benefits

• Full-time remote work.
• Competitive salaries.
• Excellent benefits including medical, dental, vision, and pharmacy.
• Merit increases.
• Flexible Spending Accounts.
• 403(b) savings matches.
• Paid time off.
• Career advancement opportunities.
• Resources to support employee and family wellbeing.