The compensation range listed reflects the range Northern Light Health anticipates relying on in setting the wages for the position. The range may not necessarily include all additional compensation elements available, such as differentials, incentive programs and benefits.
Northern Light Health
Department: Credentialing
Position is located: Cianchette Professional Blding
Work Type: Full Time
Hours Per Week: 40.00
Work Schedule: 8:00 AM to 4:30 PM
Exempt: No
Summary :
The Provider Enrollment Specialist III is responsible for performing all provider and facility enrollment and re-credentialing activities required of all NLH contracted commercial and governmental payers. The Specialist will support the maintenance of provider CAQH profiles, partner closely with the revenue cycle and operational leaders to resolve enrollment barriers, follow-up with payers to eliminate risk associated with enrollment gaps, and monitor held claims to ensure timely action.
The specialist serves as a senior resource for complex enrollment issues and may lead or participate in payer enrollment issues or enrollment initiatives, process improvement efforts, regulatory compliance activities, system implementations, and other special projects related to payer enrollment operations.
The Specialist will comply with all CVO requirements and adhere to NCQA accreditation standards as outlined in policy.
Responsibilities :
Practitioner and Facility Enrollment
- Assists with enrollment and re-credentialing application management in accordance with payer requirements.
- Partners with department credentialing staff and member hospital leadership when needed to obtain required forms, signatures, and any other required documentation needed for the purpose of enrollment or revalidation.
- Serves as department subject matter expert for all governmental payers.
- Understands specific application requirements for each payer including pre-requisites, forms required, form completion requirements, supporting documentation and regulations.
- Ensures that established provider IDs and enrollment effective dates are updated in the enrollment platform to ensure timely release of claims.
- Actively engages in issue resolution efforts to resolve enrollment rejections, enrollment delays, or troubleshoot denied claims.
- Working knowledge of the following databases: CAQH Proview, PECOS, Availity, MIMHS, and other payer portals required.
Enrollment Maintenance
- Performs enrollment tracking and timely follow-up to ensure providers are established and linked to the appropriate facility.
- Ensures accurate database management, including provider demographics and enrollment records.
- Acts as a liaison between the Medical Staff and contracted payers.
- Monitors facility enrollment and completes revalidations in accordance with payer requirements and timelines.
Policies, Procedures and Documents
In conjunction with the department leadership:
- Control and direct the administrative maintenance and support of governance documents.
- Ensure that all documents are reflective of current federal, state, and accreditation requirements
- Protect permanent records by managing a secure method of retention in accordance with the organization’s retention policies and the department’s policies.
Operations, Financial and Quality Management
In conjunction with the department leadership:
- Develop operational quality indicators which reflect meaningful measures of quality of services provided.
- Ensures that workflow, information systems and policies and procedures are current and appropriately maintained.
- Supports the completion of audits and other quality assurance activities.
CVO Operations
In conjunction with the Provider Enrollment Manager:
- Supports department leadership in managing the day-to-day operations of the enrollment team.
- Acts as a supportive resource for staff and users and identifies any tools and training necessary to perform their assigned tasks.
- Serves as lead payer enrollment educator and mentor for enrollment team.
- Promotes best practice by continually assessing payer credentialing processes and championing innovation and best practice.
- Supports department leadership by providing ongoing communication with relevant medical staff leaders and hospital administration.
Miscellaneous and Other Tasks:
- Maintains working knowledge of all computer applications needed for position including facility specific credentialing software database, Word, Excel and PowerPoint (as applicable)
- The Specialist may be assigned to various tasks such as reception, filing, direct correspondence with providers offering a “best in class” experience, or other activities required to support the general operations of the CVO.
- Continually strives to achieve individual team and departmental goals.
Other Duties
Other Information :
- Certified Provider Enrollment Specialist (CPES) or Provider Enrollment Specialist Certificate (PESC) required.
- Advanced knowledge of Medicare, PECOS, NPPES, CAQH and provider data management processes required. Experience resolving complex enrollment issues, payer denials, and enrollment gaps required.
- Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) certification preferred
Competencies and Skills
- Achieves Results: Sets high standards for their own outcomes and seizes opportunities to engage others towards objectives. Consistently moves forward with direct actions in order to attain or exceed objectives. Manages their own time effectively to accomplish assigned tasks. Successfully prioritizes multiple projects and duties as needed.
- Adobe Acrobat
- Demonstrates Adaptability: Learns quickly when facing a new problem or unfamiliar task; is flexible in their approach with changing priorities and ambiguity. Manages change effectively and does not give up during adversity. Capable of changing one's behavioral style and/or views in order to attain a goal. Absorbs new information readily and puts it into practice effectively.
- Demonstrates Emotional Intelligence: Exhibits a high level of self-awareness, self-management, other awareness and relationship management. Conducts themselves in an empathic, appropriate way, with a sense of humor and stimulates a collaborative work environment. Is respectful of the attitudes, feelings, or circumstances of others and aware of the influence of their own behavior on them. Is aware of relevant social, political, system, and professional trends and developments and uses this information for the organization's benefit.
- Develops Self and Others:Takes responsibility for engaging in professional self-development activities and programs. Strives to gain insight into their own values, strengths and weaknesses, interests and ambitions and takes action in order to enhance competencies and skills when possible. As a leader, encourages and guides employees towards growth opportunities to enhance performance and help them reach goals. Reviews and analyzes employees' strengths and weaknesses to distinguish their talents and development needs, and to ensure they are enhanced appropriately.
- Effectively Communicates: Listens, speaks and writes appropriately, using clear language. Communication methods are fitting to the message(s), audience, and situation and follow-ups are regular and timely. Shows that important (non-) verbal information is absorbed and understood and asks further questions to clarify when necessary. Expresses ideas and views clearly to others and has ability to adjust use of language to the audiences' level.
- Exercises Sound Judgment & Decision Making: Understands and processes complex information, which allows for appropriate and accountable conclusions. Does not react too quickly or slowly. Balances facts, goals, and potential approaches taking the appropriate criteria into account. Makes active decisions and commits oneself by communicating confidently and respectfully.
- Fosters Innovation: Employs and encourages the use of meaningful creativity in solving challenges. Proactively identifies opportunities and uses new approaches to enhance processes, systems and services. When appropriate, suggests or initiates new strategies, products, services, and markets.
- Influences and Inspires: Builds enthusiasm and commitment among others to move in a desired direction and models it personally. Creates a compelling vision of success that motivates workplace initiative and energizes others to follow. Provides direction and guidance to encourage cooperation between team members in order to attain an objective. Has the ability to appropriately influence others' actions and decisions with and without express authority.
- Spreadsheet application with the ability to use calculations, formulas, graphing tools, pivot tables, and a macro programming.
- Word processing, spreadsheets, data entry, database experience and other computer related skills.
- Email application with the ability to manage email as well as calendars, managing tasks and contacts, note taking, journaling, and web browsing.
- Presentation software with the ability to create presentations with the ability to incorporate animation, audio, video, time delays, as well as designing themes and variants with animations and effects.
- MS Teams
- Multi-line phone, scanner, photocopier, fax, and internet.
- Experience with operating a network.
- Public Speaking
- Seeks Process Improvement & Applies System Thinking: Possesses and gains insight into situations, problems and processes. Understands the interconnection between organizational elements. Deconstructs problems and systematically investigates the various components. Considers the impact of actions on the entire process/system. Detects problems and opportunities, recognizes important information, and links various data to trace potential causes and relevant details.
- Serves Others: Strives to understand, meet and exceed the expectations and requirements of internal and external customers which may include the people and communities in our service areas. Develops and maintains relationships, alliances and coalitions within and outside the organization and leverages them in order to obtain information, support, and promote cooperation and collaboration.
- Troubleshooting
- Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
- Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of belonging, empowerment, and cooperation.
- Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
- Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.
Education
- Required Bachelor's DegreeIn lieu of education, two years of experience is required per year of required education, exclusive of the minimum experience identified above.
Required Experience
- 5 year/years of Relevant Work Experience
Working Conditions
Work with computers, typing, reading or writing.
As an integrated health delivery system serving Maine, Northern Light Health is raising the bar with no-nonsense solutions that are leading the way to a healthier future for our state. Our care team—in hospitals, primary and specialty care practices, long-term and home healthcare, behavioral healthcare, and ground and air medical transport and emergency care—are committed to making healthcare work for you: our patients, communities, and employees.
Questions? Contact Talent Acquisition:
phone: 207-973-7100
email: [email protected]
Brewer, Maine, Corporate Office, Cianchette, Foundation, Finance, Human Resources, Legal Services
