Job Summary:
A Medicaid Provider Enrollment Subject Matter Expert (SME) ensures healthcare providers are properly credentialed, contracted, and enrolled in government-sponsored health plans. Responsibilities include managing complex enrollment applications, ensuring compliance with Medicaid/Medicare policies, auditing data, and acting as a lead contact for state enrollment systems.
Key Responsibilities
Enrollment & Credentialing: Managing and submitting accurate, timely applications to state Medicaid agencies and managed care organizations.
Policy Expertise: Ensuring compliance with federal and state regulations regarding Medicaid provider enrollment, including Fee-for-Service (FFS) and managed care.
System Auditing & Support: Supporting audits of enrollment applications, remediating data quality issues, and assisting with data mapping or provider enrollment system updates.
Relationship Management: Working with providers, clinics, and state agencies to resolve enrollment roadblocks.
Required Skills and Qualifications
Experience: Generally 3–6+ years in provider relations, credentialing, or enrollment, with deep knowledge of Medicaid/Medicare workflows.
Knowledge: Strong understanding of Medicaid regulations, credentialing standards (NCQA), and provider compensation models (e.g., FFS, risk).
Technical Skills: Proficiency in provider enrollment databases, state portals, and Microsoft Office Suite.
Education: Bachelor's degree preferred (or equivalent work experience)
