The primary purpose of this position is to enroll providers, clinicians, clinic locations, and clinical services with third party enrollment entities; such as Medicare, Medicaid, Commercial Insurance entities and the National Plan and Provider Enumeration System. The incumbent must analyze and use discretionary judgment in implementing provider enrollment guidelines to ensure all provider agreements and applications are accurate, current, and maintained.
- Prepares initial provider enrollment applications for submission by conferring with appropriate individuals and/or departments to verify information and collects appropriate licensure or certification information as required by the provider (i.e. Medicare, Medicaid, Commercial, National Provider Identifier, regulatory agencies, etc.).
- Researches conditions of participation upon notification of expansion of clinical services or location and prepares initial provider enrollment applications as required by the provider (i.e. Medicare, Medicaid, Commercial, National Provider Identifier, regulatory agencies, etc.).
- Responsible for submission of completed applications and for tracking the status of pending enrollment applications by utilizing available tools (i.e. on-line, telephone, internet, etc.) and addresses application discrepancies to ensure confirmation of enrollment.
- Audits all submitted applications by tracking coverage processing days for applications for initial enrollment, change of information and/or reassignments.
- Adheres and monitors latest changes in provider enrollment provisions; screening requirements, applicable enrollment fees, and compliance plans/requirements. Informs and educates inter and intra-departmental staff (i.e. supervisors, clinicians, providers, etc.) of changes.
- Assists clinical staff members in completing and processing provider enrollment applications. Provides education and orientation to clinical staff and guides them during the enrollment process. Develops reference and training material for inter and intra-departmental staff.
- Upon receipt of enrollment confirmation or provider separation/changes, enters appropriate provider numbers or changes into the patient accounting systems (i.e. provider maintenance) for third party billing requirements and maintains a comprehensive current list of provider enrollment numbers.
- Assists patient accounting staff in resolving discrepancies involving provider numbers and/or claims denials as a result of provider number issues.
- Assist with EHR Incentive Program Enrollments and Attestations for Meaningful Use.
- Performs other duties as assigned.
The incumbent performs complex, varied non-standardized tasks requiring applications of laws, regulations, Compliance Program policies and procedures. The complexity of the work involves working with various departments, agencies, and fiscal intermediaries covering several states and third-party payers who have different provider enrollment guidelines and forms.
MENTAL AND PHYSICAL EFFORT
The physical and mental demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
The work is primarily sedentary: walk for short periods of time and sit for long periods of time as interaction between all disciplines within the facility is required, ability to stoop and pick up objects from the floor without restrictions, and have full use of hands and arms, i.e., to operate office equipment such as computer, printer, fax, etc.
Must exercise a high degree of judgment and leadership in planning, organizing, staffing, directing, and evaluating the provider enrollment activities. Mental attention and assertiveness are always required. The ability and willingness to learn new information is an expectation.
Provider enrollment determinations and decisions effect the organization/regulatory agency relationship and the effectiveness of the patient accounting department; directly impact the funds collected resulting in the ability of TCRHCC to utilize alternate health resources effectively, optimizing reimbursements for health care rendered, which aid the overall objective of elevating the health status of Indian Beneficiaries.
TCRHCC is located within the Navajo Nation and, in accordance with Navajo Nation law, has implemented a Navajo/Indian Preference in Employment Policy. Pursuant to this Policy, applicants who are enrolled members of the Navajo Nation and who meet the necessary qualifications for this position will be given preference in hiring and employment for this position and applicants who are enrolled members of any other tribe who meet the necessary qualifications will be given secondary preference.
In performance of their respective tasks and duties, all employees at TCRHCC are expected to conform to the following:
All employees must fully uphold all principles of confidentiality and patient care. This position has access to sensitive information and a breach of these principles may be grounds for immediate termination.
I have read the qualifications and requirements for the position of Provider Enrollment Specialist. To the best of my knowledge, I believe I can perform these duties.
Associates degree in Business Administration, Allied Health, or related business field (Finance, Accounting, Administration, etc)
Must have one (1) year general administrative experience in a patient accounting setting
Other Skills and Abilities:
A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers. All employment references must address and indicate success in each one of the following areas:
- Positive working relationships with others
- Possession of high ethical standards and no history of complaints
- Has the ability to handle sensitive and confidential information
- Professional and effective interaction skills with co-workers, clients, Providers, vendors
- Ability to remain organized with multiple interruptions
- Knowledge of the operations of the front-line staff in a medical practice
- Excellent customer service skills
Bachelor’s degree in Business Administration, Allied Health, or related business field (Finance, Accounting, Administration, etc.)
- Must have two (2) years of healthcare experience in a patient accounting setting
- Knowledge of billing practices allowed by CMS regarding new providers added to the practice
- Knowledge of government and third-party insurance carrier submission requirements
Other Preferred Skills and Abilities:
Ability to speak Navajo