Summary: Demonstrates commitment to the vision, core purpose/mission and goals of LRMC, modeling the values and culture. The Payor Enrollment Coordinator works under the supervision of the Director of Managed Care to enroll, maintain, and dis-enroll health system providers in federal, state and private insurance networks. Maintains various databases of provider information including CAQH, Cactus, NPPES, PECOS, and other tracking systems/software. Understands billing implications and facilitates assignment and validation of Taxonomy Codes, Medicaid Speciality Codes and other key billing identifiers. Handles internal and external questions concerning enrollment and related matters, resolves payor enrollment issues, network participation and PCP panel changes with payor contacts and reports back to internal staff. Escalates complex enrollments issues to Director for review. Coordinates facilit/ancillary for LRMC credentialing application process, including disclosures, attestations and other documents that are signed by CFO. Coordinates timely between Recruitment and Medical Staff teams to ensure smooth processing. Must identify opportunities for and contribute to the improvement of quality, safety and cost, as well as patient, customer, and employee satisfaction.
Standard Work Duties: Payor Enrollment Coordinator - Actively participates in team development, achieving dashboards, and in accomplishing department goals and objectives. Follows all department policies and procedures. - Performs processes related to provider enrollment, changes, revalidations, and terminations with managed care and government payors. Completes all processes in a timely and accurate manner, meeting deadlines and department/payor guidelines. Ensures that providers are enrolled in correct product lines for each payor. - Updates CAQH, NPPES, and PECOS in a timely manner to reflect all new information regarding provider, including but limited to demographics, malpractice insurance and claims, and practice site location, identifiers, Taxonomy codes etc... - Coordinates with key billing issues related to enrollment, sends updates to business office and clinical staff on provider enrollment status, following department policy and procedure. - Coordinates facility, site and ancillary credentialing and re-credentialing requests as needed which include site NPI, Medicaid and Medicare site set up, and other facility credentialing. - Conducts regular audits of payors' provider directories against Cactus data on an annual basis. As often as is necessary, will validate accuracy of data on CAQH, NPPES, PECOS, Medicaid Portal. - Responds to internal and external inquiries on routine plan enrollments when requested. Works collaboratively with internal customers and payor representatives. - Organizes job functions and work assignments to be able to effectively complete assignments within established time frames. Demonstrates knowledge of all equipment and systems/technology necessary to complete duties and responsibilities Uses critical thinking skills and workload tools to manage priorities independently - Meets department and industry standards regarding volume, timeliness and accuracy. Ensures non-stop enrollment by monitoring deadlines for revalidation. Organizes workflow, prioritizes taskes, recognizes barriers and notifies Director when conflicts or barriers to efficiency exists. - Establish and maintains positive working relationships and positive, effective communication with coworkers, providers, management, and other identified stakeholders. All other duties as assigned
Qualifications & Experience
Education: Essential: * High School or Equivalent Nonessential: * Associate Degree
Experience Essential: -3+ years of experience in aspect of credentialing/enrollment and working with managed care and/or government payor related to networks, credentialing/enrollment or equivalent experience. Experience with CAQH, URAC, govermental online application. Other experience as noted in knowledge/skills -Understanding of payor networks as it relates to Primary Care, specialists, and Behavioral Health -Ability to identify and address the enrollment related elements that impact provider billing/payments, referrals, billing identifiers, and payor delegation of credentialing. -2+ years of experience working with payors to resolve billing/claim payment issues related to enrollment. Has a good understanding of how enrollment impacts payment of claims.
Experience Preferred: -3+ years of experience working with payors/providers to resolve billing/payment issues related to enrollment.
Internal Number: 6595
About Lakeland Regional Health
Lakeland Regional Health is committed to providing patient-focused, health care services while continuing to improve the quality of care to our patients, families, guests and physicians.