The Provider Enrollment Specialist is responsible for managing and coordinating the provider enrollment and re-enrollment process for all healthcare providers as well as facility enrollment and re-enrollment with payers. This includes preparing and submitting enrollment applications for Medicare, Medicaid, managed care plans, commercial and government insurance plans, as well as out-of-state payers. The role also includes maintaining MD-Staff as the system of record for provider enrollment, ensuring accurate and up-to-date provider data, tracking enrollment status and key dates, and ensuring continuous active status with payers.
This position requires close collaboration with various internal departments to support provider credentialing, onboarding and payer enrollment. It also requires close communication with payers, providers, clinic leadership and internal staff to resolve enrollment issues, track applications, and ensure compliance with all regulatory and organizational requirements. QUALIFICATIONS P referred: The ideal candidate for the Provider Enrollment Specialist position should have a minimum of two (2) years of experience in provider enrollment, credentialing, or healthcare administration.
Experience with enrollment processes for Medicare, Medicaid, managed care plans, and commercial insurance preferred. Candidates should also be familiar with various provider databases such as CAQH and NPPES, PECOS and MD-Staff or similar credentialing/enrollment database systems. Proficiency with Microsoft Office applications and the ability to effectively manage email and electronic workflows across multiple systems is required.
Strong organizational skills, attention to detail, and the ability to manage multiple priorities in a fast-paced environment are essential. Candidates must also demonstrate excellent written and verbal communication skills, particularly in liaising with internal departments and external stakeholders like payers and providers. A high school diploma or equivalent is required.
P referred: Bachelor’s degree in healthcare administration or a related field is preferred. TYPICAL PHYSICAL/MENTAL DEMANDS This position requires long periods of sitting and working at a computer, including data entry and handling electronic communication. The role may require occasional lifting of files or office supplies up to 10 pounds.
Mentally, the job demands high attention to detail, problem-solving skills, and the ability to multi-task in a fast-paced, deadline-driven environment. The employee must possess good communication and interpersonal skills, as well as the ability to adapt to changes in regulations and payer requirements. ESSENTIAL JOB FUNCTIONS: Prepare and submit new enrollment applications for providers and the facility to Medicare, Medicaid, Managed Care plans, and other insurance carriers.
Manage recredentialing revalidation and re-enrollment processes to ensure providers and facility maintain continuous active status with payers. Monitor application statuses, track application aging, and conduct routine follow up with payers to resolve issues, respond to Requests for Information (RFIs), and secure network participation. Maintain and update provider profiles in CAQH, NPI Registry, PECOS, and MD-Staff to ensure alignment with enrollment submissions.
Maintain MD-Staff database as the system of record for provider enrollment, including accurate data entry, status tracking key dates, and documentation of payer communications. Generate and maintain reports and provider rosters for payers from MD-Staff to support operational visibility and compliance requirements. Collaborate with internal stakeholders, including Credentialing, Revenue Cycle, Contracting, and Clinics, to support provider enrollment, ensure billing readiness, and facilitate timely reimbursement.
Establish and maintain relationships with payer Provider Relations Representatives to resolve enrollment discrepancies, escalate delays and improve turnaround times. Ensure compliance with federal, state, and departmental guidelines related to provider enrollment. Submit rosters to various payers every 90 days to maintain compliance with the Federal No Surprises Act (FNSA).
Support centralized tracking and visibility of enrollment activity, including identifying backlogs, upcoming expirations, and high-priority enrollments impacting revenue. Assist with facility and clinic provider data management, ensuring accurate contact details for locations. Assist the Credentialing team with initial credentialing and recredentialing applications as needed, as well as support primary source verification activities during peak volumes or staff absences.
Assist with the maintenance of credentialing files to ensure audit readiness. Coordinate with Credentialing team on provider onboarding to align credentialing and enrollment times. MARGINAL JOB FUNCTIONS: • Performs other duties as assigned.