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Provider Enrollment Specialist Resume Samples
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0-5 years of experience
Responsible for processing and maintenance of Universal Applications for Enrolled Med and CAQH Data Bases.
- Processed Enrollment requests submissions to my assigned States Commercial Payers.
- Managed work log for Application Specialists to begin Enrollment Process.
- Made follow up calls to Payers for Enrollment to confirm approval status
- Created W-9 Forms for assigned contracted HCA groups.
- Completed CAQH Maintenance for assigned HCA Contracted Providers.
- Assisted with Special Projects.
0-5 years of experience
Responsible for enrolling and credentialing Providers into Texas Medicaid
- Established relationships with Providers offices to ensure proper handling of documentation
- Provided follow through with Office Staff to ensure fast and proper handling/processing application
- Trained and Monitored new staff for quality and professionalism
0-5 years of experience
- Coordinates credentialing data needed for enrollment, contracting, and other related purposes. Credentialing data includes but not limited to medical degree, (DEA) number, state license, board certifications, CV, malpractice insurance, and state insurance form.
- Analyzes reports for physician enrollment, re-enrollment and dis-enrollment to measure timely completion in accordance to contract agreements.
- Revises all system-generated report errors and looks for global issues that can be corrected through process improvement.
- Develops and maintains relationships with external physicians and Managed Care Health Plans.
- Developed and administered innovative team building strategies that improved communication, leadership skills and diversity awareness in clinical settings within a 6 month period.
0-5 years of experience
Prepares and submit applications to Medicare and Medicaid for new provider enrollments and existing provider updates; follow up by telephone or in writing, with carriers regarding application status
- Requests NPI numbers for providers and clinics as necessary and maintain NPI files.
- Follows up, either by telephone or in writing, with insurance companies and patients regarding the processing of outstanding claims and or appeals
- Utilize the enrollment database to perform queries and reports for manager
- Identify issues that require additional investigation and evaluation, validates discrepancies and complete appropriate follow up
0-5 years of experience
- As Credentialing Specialist, responsible for Ambulatory Surgery Center privileging and re-privileging process for initial and current providers, including primary source verifications and processing.
- Update and maintain ECHO software for credentialing department including updating provider information, and adding new providers.
- Run data quality reports and reviews files and online provider databases for accuracy and errors.
- Coordinate the credentialing and re-credentialing of providers participating in the Integrated Eye Care Network.
- Responsible for tracking and updating expiring provider credentials including state license, DEA and annual training programs.
- In the role of Provider Enrollment Specialist, completed ‘A to Z’ managed care credentialing and re-credentialing for 40+ providers with more than 25 health plans.
- Conducted follow-ups with health plan credentialing and provider relation representatives on credentialing, re-credentialing and demographic updates.
- Was responsible for the creation, editing and upkeep of a managed care credentialing manual for the credentialing department.
- Created and maintained CAQH provider profiles for new and existing providers on an ongoing basis. Reviewed profiles for errors and corrected accordingly.
- Received positive end of year employee reviews for 2014, 2015, and 2016 while meeting year-end goals.
6-10 years of experience
- Responsible for completion and follow-up of provider applications including Medicare, Medicaid and top commercial payers for multiple states. Able to multi-task and prioritize workload resulting in timely submitting and processing of provider applications. Research insurance issues and effectively communicate with billing staff the progress of approved provider numbers.
- Develop and maintain strong relationships with clinic and hospital staff to obtain necessary credentialing documents required to complete and submit accurate applications. Communicate and advise the physician, mid-level or designated contact person of sequential steps needed to begin enrollment, through completion.
- Served as team lead by offering guidance and support to fellow team members. Support Supervisor with various assigned duties and back up as needed. Maintained provider enrollment work load in addition to Team Lead duties
0-5 years of experience
- Currently maintaining record of 630 individual providers.
- Communicate and advise hospital CEO or designated contact person of the needed paperwork necessary to begin the application process for new physicians through completion.
- Contact top insurance plans (government and commercial) to request provider enrollment application packages, and to continue to follow-up with insurance plans by telephone or email until all provider numbers are issued.
- Validate CAQH attestation as well as CAQH maintenance
- Follow up on all re-credentiailing & revalidation requests as received.
- Key all provider demographic and enrollment data into Vistar and Care Computer System
0-5 years of experience
Verifies provider enrollment application approval with health plans (Medicare, Medicaid)
- Maintains up to date provider enrollment documentation.
- Processes 200 to 250 assignments per month while maintaining above a 96% quality rating.
- Follows up with providers to ensure forms are completed in a timely manner.
- Completes provider enrollment applications and written requests.
- Prepares correspondence to send to providers and health plans via fax, email and postal mail.
- Creates enrollment and provider by practice analytical reports to identify key provider demographic information.
- Utilizes a tickler filing system to track when signed applications, health plan approvals, and follow ups are to be completed daily.
- Calculates any open accounts receivables due to the providers from the health plans and resolves any outstanding balances due in excess of 100k for closure.
- Completes special projects within time frames given by management.
- Meets or exceeds quality and quantity productivity standards monthly.
0-5 years of experience
- Prepare, submit, and follow up on all initial payer applications for government programs and company approved managed care organizations, as well as recredentialing applications for all providers and practice locations
- Collect and maintain files in relation to credentialing of network providers including current provider licenses, DEA certificates, malpractice insurance, board certifications, and other pertinent forms need for enrollment
- Advise management team of any potential delays in a providers enrollment and work with billing office staff in resolving billing issues related to payer enrollment issues
- Routinely review and update provider files and rosters including, but not limited to individual/group CAQH profiles, payer databases, NPI/NPPES, PECOS, and any others
- Update billing database, Intellicred, once a provider has been approved and assigned provider numbers are obtained
- Communicate with all necessary internal departments, as well as develop and maintain relationships with individual contacts for government agencies and managed care organizations
- Maintain consistent contact with providers and practice directors to ensure expectations are clear and requirements are completed in a timely manner
- Complete other tasks or projects as assigned
0-5 years of experience
- Enrolling over 150 provider with over 1100 payer lines for Florida and Georgia
- Initiating and completing various payer applications specific to their enrollment regulations
- Perform payer research for specific requirements
- Maintain relationship between providers and Office Manager ensuring all documentation is received and upon completion of enrollment
- Maintained accurate documentation in CARE system for progress of enrollment and provider documentation
- Timely follow up with payers to ensure receipt of application and needs to complete enrollment
- Update CAQH/PECOS
0-5 years of experience
- Prepare, submit and follow-up on all initial payer applications & re-credentialing applications for providers and clinic locations.
- Track current status of applications, follow up as necessary and document activity in StatCred database in an accurate and timely manner.
- Maintain and update provider files and rosters including but not limited to: internal provider and/or location roster lists, individual CAQH profiles, payer databases, NPI/NPPES, PECOS and any other as needed.
- Ensure credentialing and licensing processes are completed in a timely manner and notifications are sent accordingly.
- Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
- Maintains strict confidentiality with regard to protected health information understands and adheres to Sound Physicians HIPAA Privacy & Security policies and procedures.
0-5 years of experience
Medicaid Provider Enrollment
- Processed multiple provider types for enrollment to participate in the Pennsylvania Medicaid program.
- Verified multiple provider type credentials to complete application processing.
- Navigated various computer systems to retrieve, obtain, verify & enter information accurately and efficiently.
0-5 years of experience
- Enroll optometrist in 7 different states with Vision and Medical insurance including Medicare and Medicaid
- Provider assistance to our billing team with denial issues due to credentialing reasons
- Learn how to enroll new insurances
- Help with the training process of new and current employees
0-5 years of experience
- Verifying correct enrollment numbers and mailing completed agreements to the proper payer/vendor for approval.
- Following up with clients, payers and vendors to insure receipt of forms and approval by payers/vendors prior to submission by client.
- Entering all required information and approvals into the TPS and Enroll Link system for new providers, products and services to new sites.
- Answering incoming calls to the Provider Enrollment Department.
- Working pre-billing and production reports associated with new providers, products and services.
0-5 years of experience
- Interact professionally with providers and ancillary staff to provide appropriate and timely response to inquiries and concerns regarding provider enrollment and file maintenance for Medicaid programs (including dental, vision, ambulance, physicians, nurses and all other provider types).
- Process to completion 100% of assigned applications utilizing documented work instructions daily and meet daily quotas.
- Complies with Medicare and Medicaid provider enrollment guidelines.
- Send out deficiency letters to notify providers of incomplete/inaccurate applications. Revise existing deficiencies based on QA audits
- Respond to inquiries regarding status of applications received
- Research and contact providers to resolve enrollment application deficiencies
- Send out provider applications, forms and other provider correspondence as requested
- Maintain strict confidentiality of information and job files as dictated by current HIPAA requirements
- Perform other duties as assigned by leadership
0-5 years of experience
- Prepare submit and follow up and all medical payers application and re-credentialing application for all providers and clinic locations.
- Contact and/or respond to requests for verification of credentials current license
- Advice management team of any potential delays in a providers enrollment and work with billing office staff in resolving billing issues related and payer enrollment issues
- Track current status of applications, follow up as necessary and document activity in accurate and timely manner
- Update billing database once provider approved and provider numbers are obtained.
- Maintain and update provider files and rosters including but not limited to individual/group CAQH profiles, payer database, NPI /NPPES, PECOS and others as needed
- Maintain consistent contacts with providers to ensure expectation are clear and requirements are completed in a timely manner
0-5 years of experience
- Validates the accuracy of data submitted utilizing various electronic databases
- Ensures accurate entry of data into CMS’ national database for all CMS providers and suppliers
- Processes initial applications, changes of information for existing providers, and processes electronic funds transfers
- Reviews sales agreements and bill of sale for change of ownership agreements
- Reviews the agreement between CMS and the FQHC as well as the Health Resources and Services Administration grant for Federal Qualified Health Centers
- Determines and then forwards recommendations to CMS and state agencies as to whether the application should be approved or denied
- Maintains an understanding of the CMS directives and follows all processes and procedures in order to maintain the integrity of the program
- Responsible for monthly Award Fee document which includes obtaining metrics, data and generating narratives for 9 operational areas to be submitted to deputy director of MAC
- Use of SharePoint to obtain information from operational areas and to list/track issues requiring the attention of CMS
0-5 years of experience
- Responsible for all activities associated with credentialing providers and physicians.
- Ensures that all enrollment applications are processed in accordance with Florida Agency for Healthcare Care Administration.
- Maintains detailed provider enrollment files in electronic format.
- Works collaboratively with fellow team members to create, and maintain department workflows, processes, policies and systems
0-5 years of experience
- Implement physician and hospital enrollment process for clients who request provider enrollment services.
- Communicate with various payers to obtain missing documentation and credentials to complete provider enrollments
- Maintain provider information and demographics for all providers
- Coordinates re-enrollment packets for hospitals and physicians
0-5 years of experience
- Accurately updating provider’s records
- Processing new enrollment paperwork and outreaching to providers to resolve issues
- Running reports to ensure provider records are correct
- Creating Excel charts and PowerPoint presentations for management meetings
0-5 years of experience
- Process enrollment applications for Medicaid providers. Updated change request and spread sheets daily.
- Add and update (ACH) direct deposit information to provider and group’s accounts.
- Process Attestations forms also make copies and send/receive faxes.
- Answer calls from providers regarding enrollment issues.
0-5 years of experience
- Responsibilities are to have a thorough understanding of Medicaid processes and requirements for Rendering Providers and Service locations to ensure eligibility to receive payment for Medicaid services. Meet state service level agreements for timely processing of cases provided by Medical Providers.
- Extensive research into multiple License/DEA/Certification/CLIA sites and ensures all requirements have been met for each individual Provider Type and Specialty; outreach to providers if any information is missing or needs further verification.
- Extensive use of Excel spreadsheets, able to adjust to a daily change in work processes, able to organize and share information received in multiple trainings with team members to help better understand. processes, state service level agreements and requirements
0-5 years of experience
- Reviewed and processed Drs. Application.
- Screened and checked for any discrepancy.
- Called, screened and verified their locations of practice or practices.
- Checked them in the CMS and Pecos system.
- Verified their PTANs.
0-5 years of experience
- Performs Enrollment Inquiries for Texas Health Steps Medical, Texas Health Steps Dental, PCCM and CSHCN (Children With Special Healthcare Needs) programs
- Review Kintana Tickets and pull Medicaid provider Applications
- Assists providers with application corrections and submittal
- Researches Medicaid policies and procedures through references such as the Medicaid Provider Manual, Bulletins and Banner Messages, and the EOP.
0-5 years of experience
- Prepare and submit provider enrollment applications for managed care plans e.g. Aetna, Cigna, UHC, etc in various products e.g. HMO, PPO, etc
- Prepare and submit provider enrollment applications for Medicare (via PECOS) and Medicaid for Texas, New Mexico, Oklahoma, and Louisiana.
- Maintain CAQH profiles with most current provider information
- Monitor enrollment to identify any processing problems.
- Monitor OIG (federal and state level), NPDB and other compliance sites for disciplinary issues or sanctions.
- Complete disenrollments as needed
- Daily contact with health plans and providers regarding status of enrollment/credentialing, and/or any issues with enrollment, billing or contracting.
- Data entry integrity/monitoring
0-5 years of experience
- Communicate & advise Hospital CEO or designated contact person of required documents needed to begin application process for new groups/physicians.
- Obtain completed Notification Form & CHS Provider Contract from provider contact for all enrolling providers.
- Maintain contact wih designated contact person to obtain application signatures and required documents to complete application for processing.
- Key all provider demographic & enrollment data into Vistar Computer System
- Scan all related enrollment documents into Vistar Computer System
- Contact Health plans to request provider enrollment packets and continue follow-up with contact by telephone or email until all providers are enrolled.
- Prepare & distribute a Provider Grid to designated contact person for each provider in order to communicate provider enrollment numbers.
- Begin recredentialing for providers as needed.
- Complete applications for new acquisitions.
- Complete applications for Medicaid
0-5 years of experience
- Credentialing specialists maintain regular cooperation and compliance with all regulatory, accrediting, and membership-based organizations.
- Create and carry out various credentialing processes in relation to physicians, medical assistants, and various other healthcare professionals. Ensures that all personnel and services adhere to facility and staff policies, department guidelines, regulations, and government laws.
- Process Medicaid applications and reappointment paperwork, checking for full completeness and accuracy.
- Collect and process significant amounts of verification and accreditation information, and thus must constantly maintain and update accurate databases for both practitioners and facilities. These databases include pertinent education, training, experience, and licensure content. Prepares their own records for regular auditing, as well as maintain close communication with all appropriate practitioners to ensure that records are up-to-date and consistent.
- Collaborates with the Quality Management System and Medical Staff Credentialing to ensure regulatory guidelines are maintained.
- Provide administrative support to Credentialing staff.
- Processes credentialing and re-credentialing applications of health care providers.
- Contacts medical office staff, licensing agencies, and insurance carriers to complete credentialing and re-credentialing applications
0-5 years of experience
- Prepare and submit credentialing applications and support documentation for the purpose of enrolling individual physicians and physician groups with payers
- Manage the completion and submission of provider enrollment applications
- Maintain documentation and reporting regarding provider enrollments in process
- Retain records related to completed provider enrollments
- Maintain provider enrollment information within the credentialing data base
- Respond to inquiries regarding status of applications received
- Follow up with insurance plans to monitor status of provider applications
- Research and contact providers to resolve enrollment application deficiencies
- Send out provider applications, forms and other provider correspondence as requested
0-5 years of experience
- Auditing
- Maintaining insurance files and contracts
- Accounts Receivable Specialist
- Medical Billing – laboratories
- Provider insurance contracting-PPO, Medicare, Medicaid, and HMO
- EFT, ERA, and EDI
0-5 years of experience
- Expert knowledge of Provider Enrollment Medicare rules and regulations.
- Extensive review of Provider/Supplier enrollment and application processing history to determine if all CMS regulations were followed to establish a favorable or unfavorable decision during appeal process.
- Assists in the implementation of standard operating procedures and workflows for multiple processing functions.
- Proficient in all areas and systems utilized during the Provider Enrollment process including but not limited to Microsoft Programs.
- Expert knowledge in processing guidelines of Centers of Medicare and Medicaid Services Provider Enrollment applications and responsible for processing of said applications.
- Performs clerical tasks including but not limited to compiling data, verifying data, and telephone correspondence with Provider’s and/or their established contacts.
- Works with Provider’s and/or their established contacts to ensure all required information and documentation are submitted and complete for enrollment eligibility/appeal rights while maintaining a customer focus mind set ensure the provider is satisfied and/or fully understands the deficiencies in their enrollment.
- Meets and exceeds expectations for production and quality audits
- Works independently to identify problems, research information, and offer solutions in multiple special projects.
- Review of associate processing to create customized training plan to enhance their quality and production processing.
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Last edited by: Gabriela Barcenas, CPRW, Content Writer II -
Gabriela Barcenas
CPRW, Content Writer IIGabriela is a Certified Professional Resume Writer (CPRW) and career adviser. With 10 years of digital media experience and five years of resume writing expertise, her publication history includes fashion, education, travel, social justice, equitable design and career advice.
