Provider Network Specialist

Gila River Health Care Sacaton , AZ 85247

Posted 7 months ago

Overview

Responsible for preparing and submitting enrollment applications and supporting documentation for the purpose of enrolling individual department licensed professional staff members with payers for billing purposes.

Verifies the professional licensing, training, and certifications and ensures that professional licensing, training, and certifications required for department licensed professionals meet all federal and state medical standards, The Joint Commission (TJC), Center for Medicare Services (CMS), as well as NCQA (National Committee for Quality Assurance) requirements. Responsible for the accuracy and integrity of the enrollment database system and related applications.

Responsibilities

  • Manage and process the completion and submission of insurance enrollment applications to participating insurance plans for claim, billing and revenue purposes; checking for full completeness and accuracy.

  • Research and resolve any enrollment application deficiencies.

  • Follow up with insurance plans to monitor status of provider applications

  • Ensures that licenses and credentials are valid, accurate, and properly documented to meet insurance company preferences and state/federal insurance regulations.

  • Maintains and continually updates personal knowledge of credentialing standards, bylaws, regulations and regulations, policies, and requirements for department.

  • Analyzes and reviews individual certification, license and credentials information to ensure current validity on a continuing basis.

  • Ensures pertinent documents are received from practitioners for credentialing

  • Utilizes a variety of professional records, indexes and storage/retrieval systems to maintain accurate records. Prepares records for regular auditing.

  • Performs sanction research and reporting.

  • Re-enrolls providers terminated by insurance carriers.

  • Performs all follow-up necessary to ensure that all required data and information is received on a timely basis and deadlines are met.

  • Provides assistance to providers regarding National Provider Identifier registration.

  • Collaborates as needed with GRHC Medical Staff Services Credentialing Department.

  • Demonstrates ability to relate to diverse cultures and specifically the Gila River Community and/or other Native American cultures and community health services.

  • Performs other special projects and duties as assigned.

Qualifications

  • High school Diploma required, Associates Degree in a health care related field preferred

  • 1 year of health care insurance enrollment experience required.

  • Demonstrated ability to relate to diverse cultures and specifically the Gila River Community and/or other Native American cultures.

  • Demonstrated ability to regularly change priorities to accomplish all tasks despite frequent interruptions.

  • Demonstrated ability to clearly communicate, both orally and in writing.

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Provider Network Specialist

Gila River Health Care