Provider Enrollment Specialist

Role Overview

The Provider Enrollment Specialist operates under the guidance of the Provider Enrollment Supervisor, tasked with maintaining records for both participating and non-participating providers within the provider database. This role involves managing claims flagged in the invalid provider queue, addressing provider-related claim suspension issues, facilitating the panel transfer process, executing assigned projects, and liaising with internal and external clients regarding provider maintenance.

Responsibilities

• Communicate provider updates to relevant providers, members, and internal departments promptly within designated timeframes.
• Organize provider mailings for claims that are unprocessable due to incomplete or invalid information.
• Investigate and resolve issues with returned checks and provider mail correspondence.
• Assist providers and internal customers by addressing inquiries related to Panel Transfers, Panel Releases, and Special Needs Primary Care Provider assignments.
• Prepare departmental reports, maintain logs, and complete documentation as assigned.
• Adhere strictly to service level agreements (SLAs) to ensure timely completion of tasks.
• Participate in mandatory annual training and comply with organizational policies and standards.

Qualifications and Experience

• Possession of an Associate’s degree or comparable professional experience.
• At least one year of healthcare-related experience is required.
• Background in claims processing is advantageous.
• Familiarity with different provider roles and healthcare claims processing is preferred.

Skills and Competencies

• Competency in Microsoft Office suite including Word, Excel, Access, and Outlook.
• Experience using Facets software is a plus.
• Attention to detail coupled with strong organizational capabilities.
• Effective communication skills for interactions with providers, members, and cross-functional teams.
• Analytical and problem-solving skills for addressing provider-related challenges.

Benefits

The role offers flexible working options such as remote or hybrid schedules, competitive compensation, paid leave including holidays and volunteer opportunities, health insurance coverage effective from day one for employees and dependents, a retirement savings plan via 401(k), tuition reimbursement programs, and additional benefits.

About AmeriHealth Caritas

AmeriHealth Caritas, based in Newtown Square, Pennsylvania, is a mission-oriented healthcare organization with over three decades of experience delivering comprehensive, outcome-focused care services. Their portfolio includes managed care products, pharmaceutical benefit management, specialty pharmacy, behavioral health, and administrative services, with a commitment to advancing healthy communities nationwide.