Provider Enrollment Specialist

• Coordinate and oversee all aspects of initial credentialing/enrollment for the Managed Care plans for all billable PO and hospital providers.
• Collaborate with PO Foundations, hospital finance and Medical Staff Services to ensure successful and timely enrollment of all billable providers.
• Ensure that the credentialing information is sent to the Managed Care plans promptly and maintains compliance with all relevant internal and external policies, procedures and accreditation standards (e.g. Insurance Plan, MCO, and/or State)
• Ensure accuracy of all CAQH (Council for Affordable Quality Healthcare) data entry for all billable providers. Ensure that attestations are routinely acted upon in the CAQH database.
• Ensure that the credentialing information in CAQH is kept up-to-date. Ensure that we are compliance with all applicable Managed Care Contracts and Delegated Contracts.
• Complete all Medicare enrollments for providers via the online PECOS (Provider Enrollment, Chain, and Ownership System) system.
• Coordinate and oversee all aspects of re-credentialing and/or revalidations for the Managed Care plans for all billable providers, Foundations and the hospital.
• Follows-up with the departments on any overdue re-credentialing documentation.
• Maintain and updats MD Staff database with accurate information for all billable providers including uploading copies of all submitted applications and welcome letters to the appropriate plan in the provider’s file.
• Maintain MD Staff database with enrollment status of applicable providers for all insurance plans to include effective dates and provider ID numbers for all insurance plans the providers enroll with to ensure timely submission of bills.
• Ensure the database is up to date with all accounting of communications to the relevant plans.
• Compile, evaluate and present practitioner-specific data collected for review by the Physicians Organization in a comprehensive and timely manner.
• Document, according to policy and procedure, applicants, and re-applicants with potential issues holistically and comprehensively.
• Coordinate the out-of-state Medicaid enrollment process for all billable providers by current enterprise policy. Work closely with the billing department to identify providers needing out-of-state Medicaid enrollment via various EPIC Work Queues.
• Ensure a timely and efficient enrollment in all 50 states by understanding and complying with their various rules and regulations.
• Update provider’s enrollment status once achieved in the EPIC Work Queues and MD Staff database for the appropriate out-of-state plans to ensure timely access to patient care and billing submission
• Coordinate the out-of-state Medicaid follow-up process. Ensure a timely and efficient process by coordinating with all appropriate Foundation, hospital, and billing contacts.
• Ensure physicians are re-enrolled as needed. Update the billing department promptly regarding all provider re-enrollments so that any affected claims can be submitted.
• Coordinate all enrollment for non-billing providers as required by MassHealth for ordering, referring, and prescribing purposes.

To qualify you must have:

• Two years of post-high school education or an Associate’s Degree.
• 2 years of related experience in a medical office setting.
• Additional 2 years of directly related provider enrollment experience may be considered with a High School diploma in lieu of a two-year degree.

Boston Children’s Hospital offers competitive compensation and unmatched benefits including flexible schedules, affordable health, vision and dental insurance, child care and student loan subsidies, generous levels of time off, 403(b) Retirement Savings plan, Pension, Tuition and certain License and Certification Reimbursement, cell phone plan discounts and discounted rates on T-passes. Experience the benefits of passion and teamwork.

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