Provider Enrollment Specialist

Description

The Provider Enrollment Specialist is responsible for managing the enrollment and re-enrollment of physicians, advanced practice providers, and other clinical staff with Medicare, Medicaid, and commercial payers. This role ensures timely and accurate provider enrollment to support optimal reimbursement, compliance with regulatory requirements, and uninterrupted patient care delivery.

This position plays a critical role in maintaining the hospital’s cost-based Medicare reimbursement status, managing unique enrollment processes, and supporting rural healthcare operations where efficient revenue cycle processes are essential for financial sustainability.

Key Responsibilities

• Prepare, review, and submit initial and re-enrollment applications for all providers to Medicare (via PECOS), Medicaid, and commercial insurance payers.
• Manage CAH-specific enrollment requirements, including facility and individual provider enrollments, reassignment of benefits, and compliance with Medicare Conditions of Participation.
• Coordinate with providers, medical staff office, and credentialing teams to gather required documentation (licenses, certifications, malpractice insurance, DEA, NPI, etc.).
• Track application status, respond to payer requests for additional information, and follow up diligently to secure approvals within established timelines.
• Maintain accurate provider enrollment records in internal systems, CAQH Pro View, NPPES, and payer portals.
• Monitor revalidation schedules and ensure timely submission to prevent lapses in billing privileges.
• Assist with troubleshooting claim denials related to enrollment issues and collaborate with billing teams to resolve payer-related problems.
• Serve as a liaison between the hospital, providers, and payers to resolve enrollment and credentialing issues.
• Conduct regular audits of enrollment data for accuracy and compliance.
• Stay current with changes in payer policies, Medicare regulations, and CAH-specific guidelines affecting provider enrollment.
• Support onboarding of new providers and locum tenens staff by expediting enrollment processes.
• Generate reports on enrollment status and timelines for leadership.

Requirements

Education:

• Associate’s degree in Healthcare Administration, Business, or related field required;
• Bachelor’s degree preferred.

Experience:

• Minimum 2–3 years of experience in provider enrollment, credentialing, or medical billing in a hospital or healthcare setting.
• Experience with Critical Access Hospitals or rural healthcare preferred.
• Familiarity with Medicare PECOS, CAQH, NPPES, and state Medicaid enrollment processes strongly preferred.

Knowledge, Skills, and Abilities:

• Strong understanding of healthcare regulatory requirements, including HIPAA, Medicare Conditions of Participation, and payer contracting guidelines.
• Proficiency with enrollment software, EHR/Practice Management systems, and Microsoft Office Suite (especially Excel).
• Excellent attention to detail, organizational skills, and ability to manage multiple deadlines.
• Strong interpersonal and communication skills to interact effectively with physicians, clinical staff, and payer representatives.
• Problem-solving skills with the ability to navigate complex enrollment scenarios.
• High level of integrity and commitment to compliance and data accuracy.

Certifications (Preferred):

• Certified Provider Enrollment Specialist (CPES) or
• Certified Professional Medical Services Management (CPMSM) / Certified Provider Credentialing Specialist (CPCS).