Provider Enrollment Specialist II - GHI / NGPG - Remote - Must live in Georgia - Mon - Fri 8:00am - 5:00pm

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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

This position shall perform complex functions related to the enrollment in Governmental and Commercial plans for Practitioners employed by the Northeast Georgia Physician Group and/or affiliations. This includes the processing of all Medicare, Medicaid and Managed Care payor applications, initial & re-appointment. Further this position shall effectively communicate pertinent information to all necessary individuals and entities in a timely and accurate manner. This position has knowledge of a widely used concepts, practices, and procedures. Relies on experience and judgment to plan and accomplish daily work. 
 

Minimum Job Qualifications

• Licensure or other certifications:

• Educational Requirements: High School Diploma or GED.

• Minimum Experience: Minimum of three (3) to five (5) years experience working in Provider Enrollment environment to include provider enrollment, credentialing, and/or provider relations or healthcare related setting required.

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements: Bachelors Degree.

• Preferred Experience:

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Experienced working with Medicaid, Medicare, Medicaid CMOs and other governmental payors in enrolling providers

• Accustomed to working with commercial and governmental payors in a delegated arrangement and responding to deadlines

• Experienced in credentialing providers with commercial plans following NCQA accreditation standards

• Demonstrates a solid understanding of the various operational aspects of managed care to include provider enrollment, credentialing and provider relations

• Must be detailed oriented with excellent organizational and computer skills

• Must be able to make logical judgments, utilizing independent decision making skills appropriately

• Strong written and verbal communication skills and the ability to communicate effectively with people on all levels

• Demonstrate ability to function as part of a team, as well as be highly self-motivated

• Must have ability to handle multiple projects at the same time, establish priorities and perform under deadline pressures

• Exemplifies the organization's customer service standards

• Improves work processes

• Complies with confidentiality rules, polices, and regulations in all aspects of the job

• Demonstrates working knowledge of safety practices

• Responds positively to change regarding work.

• Demonstrates respect for co-workers

Essential Tasks and Responsibilities

• Enrolls Physicians and mid-level Providers in:(a) commercial plans, and (b) government payor plans to include Tricare, Medicaid CMOs and those that require the Council for Affordable Quality Healthcare (CAQH) . On an on-going basis, prepares and submits provider enrollment and re-enrollment applications for NGPG Physicians and mid-level providers, in accordance with DOH plans. Completes all requests for re-credentialing purposes.

• Works with the providers and the Practice Managers to facilitate timely completion of applications and submits applications to payors to meet established deadlines in accordance with payor specific documentation and submission requirements.

• Verifies all supporting documents that are needed for enrollment are received from Recruitment and are legible, current and completed correctly. Follows-up with the provider, the Credentials Verification Office (CVO) and/or Recruitment to secure missing documents.

• Monitors provider non-compliance with enrollment requests and notifies management of delays that can impact reimbursement.

• Prepares and submits monthly, or as needed, delegated rosters to payors in accordance with delegated agreements to ensure timely effective dates for billing and payment purposes. This includes new and changed information. Monitors receipt and follow-through.

• Tracks monthly timeliness of provider loads by payor to include date submitted, date confirmation received, error rate and corrections needed. Reports non-compliance to management for further direction. Retains communication in an orderly fashion for reference purposes.

• Audits on a monthly basis provider loads once confirmed by the payor for accuracy. Report, by way of written correspondence, the errors that need to be corrected to the payor. Report findings to management. Monitor progress and resolution. Schedule conference call and/or meetings with payor representatives to address issues.

• Notifies payors to maintain current provider information including, but not limited to, changes in practice addresses, contact information, name changes, board status and resignations.

• Ensures that eleven (11) distinct applications, processes and/or proprietary documents are completed for enrollment purposes, to include the GA Uniform part I and II, CAQH, BCBS, delegated payors, Amerigroup, Peachstate, Wellcare and Tricare, following established internal procedures.

• Follows-up on rejected documents from the payors. Corrects and resubmits on a timely basis. Retains records for reference purposes.

• Completes and submits payor specific enrollment applications and spreadsheets for existing providers that want to add additional practice locations or are moving from one practice to another.

• Prepares and submits applications, specific to Anthem, for providers to practice in the Urgent Care centers and prepares proprietary forms required to enroll providers as directed. Responsible to complete and submit entity applications for Anthem.

• Monitors receipt of payor effective date notices. Contacts payors to follow-up on enrollment status, secure provider numbers, effective dates and confirmation letters. Enters effective dates and provider numbers on the Medicred. Scans approval letters into each provider's file for reference purposes. Notifies key personnel when updates are made.

• Enters and updates all provider demographics into Apogee for tracking and reporting purposes. Notifies the CVO when changes are needed.

• Takes the lead with payors in monitoring the progress of enrollment. Notifies management of payor noncompliance.

• Maintains files in an orderly and secure fashion. Creates e-files to house enrollment documents and related correspondence. Initiates a provider enrollment tracking form for each provider to monitor progress. 

• Supports management in all aspects of provider enrollment to include reporting, meeting attendance and department projects as needed.

• Tracks carrier requirements as related to provider enrollment to ensure that all regulations are met.
   

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Constantly 66-100% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Occasionally 0-30%

• Job Requires: Reading, Writing, Reasoning, Talking

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals. 

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.