JOB TITLE: Payor Provider Enrollment Specialist

FLSA: Exempt

REPORTS TO: Director of Patient Financial Services

Under the supervision of the Director of Patient Financial Services, the Payor Provider Enrollment Specialist administers the credentialing, re-credentialing and delegated processes related to payer provider enrollment (credentialing). The incumbent works independently to coordinate, develop, monitor, and maintain the credentialing/payor provider enrollment process.

MAJOR DUTIES/ESSENTIAL FUNCTIONS

Essential and other important responsibilities and duties may include, but are not limited to the following:

• Implements and oversees all activities related to licensed independent provider delegated credentialing.
• Implements and oversees all activities related to health professional's payer credentialing and re-credentialing.
• Performs regularly scheduled audits of the payer credentialing files.
• Assists in developing payer credentialing policies and procedures.
• Maintains knowledge of HRSA, NCQA, and Joint Commission credentialing requirements.
• Monitors regulatory sources to stay informed of rapidly changing rules and regulations that relate to credentialing processes.
• Reviews and processes all payer credentialing applications.
• Analyzes and resolves file issues, tracks progress on the database, and produces weekly reports as requested by the Director of Patient Financial Services.
• Responds to provider inquiries received by any form of communication.
• Handles administrative meeting issues as required.
• Will carry out moderately-complex, multi-step instructions, and makes appropriate independent decisions, as necessary.
• Maintains close contact with Patient Financial Services Department to provide updates on new hires, terminations, approvals from MCOs, and any other information the PFS department could need from payer credentialing, or vice versa.
• Maintains and updates the providers CAQH files, PECOS, NPPES and any other payer credentialing website as appropriate.
• Works closely with all the in-network payers' credentialing contacts to ensure a streamline credentialing and enrollment process.
• Resolves areas of concern in accordance with UHC's policies and procedures regarding professional behavior.
• Performs other duties as assigned.

REQUIRED QUALIFICATIONS

• Bachelor's degree OR an equivalent combination of education and experience which provides the required knowledge, skills and abilities deemed sufficient to prepare the applicant to successfully perform the duties of the position.
• Five years of ambulatory physician payor credentialing OR an equivalent combination of education and experience which provides the required knowledge, skills and abilities deemed sufficient to prepare the applicant to successfully perform the duties of the position.
• CPCS certification required within first year of employment.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Effective verbal and written communication skills to communicate with providers, Managed Care Companies, and hospital personnel via phone, email and through prepared correspondence.
• Demonstrated creativity, flexibility, and goal-oriented ability.
• Ability to work independently in a team-oriented environment and interact well with individuals with diverse ethnic and cultural backgrounds and needs.
• Demonstrated oral and written communication skills.
• History of positive customer relations as demonstrated by supervisor recommendation.
• Ability to perform presentations and interact with many different levels of UHC leadership.
• Ability to work independently with minimum supervision.
• Demonstrated ability to effectively work and communicate with diverse populations.
• Demonstrated proficiency with business software (e.g. Microsoft Office Suite). Experience with database reporting.

This is an exempt position which reports directly to the Director of Patient Financial Services.

GUIDELINES

The position abides by all rules and regulations set forth by applicable licensing and regulatory bodies and the UHC policies and procedures.

PERSONAL CONTACTS

The position requires contact with staff at all levels throughout the organization. There are also external organization relationships that may be part of the work of this individual.

PHYSICAL EFFORT AND WORK ENVIRONMENT

• Refer to the attached ADA check list.

OTHER SIGNIFICANT FACTS. The incumbent must be able to balance the needs of diverse constituencies on a daily basis.

RISKS

The position involves everyday risk and discomforts, which require normal safety pre-cautions typical of such places as offices, meetings, training rooms, and other UHC health Care Sites. The work area is adequately lit, heated, and ventilated. All medical services shall be provided according to medically accepted community standards of care. The employee shall provide evidence of recent (within the past twelve (12) months) health assessment that includes a PPD and/or chest x-ray results.

The statements contained herein describe the scope of the responsibility and essential functions of this position, but should not be considered an all-inclusive listing of work requirements. Individuals may perform other duties as assigned including work in other areas to cover absences or relief to equalize peak work periods or otherwise balance the workload.