Payer Enrollment Specialist

New Haven, CT
Jan 12, 2019


Job Description

To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.


Under the direction of the Manager, Payer Enrollment and Delegation, the Enrollment Specialist is responsible for the enrollment of Yale New Haven Health System practitioners with non commercial payers (Medicare, Medicaid, Tricare). This includes initiating the enrollment process from notification that a new practitioner has been added to the network and collaborating with Credentialing Specialists within Medical Staff Administration and the practitioner to complete the application process. This involves accurate and timely entry of provider data including contact information, status changes, and ensuring that verification of all required credentialing criteria has been completed in accordance with all policies and other applicable standards. The position also includes responsibility for ensuring that the re-verification process and any interim or re-credentialing activities required by government payers occurs to ensure continuous, uninterrupted participation status for all practitioners. This position maintains up to date and thorough knowledge of non-commercial payer enrollment obligations at the State and Federal level.

  • 1. Completes the government payer enrollment process for all new practitioners within established timeframes.
  • 1.1. Obtains information needed for government payer application process from information on file or already available within Medical Staff Administration from the Medical Staff appointment process.
  • 1.2. Contacts practitioner directly for any additional documentation or information needed.
  • 1.3. Enters complete information into MSOW Network Management accordingly.
  • 1.4. Ensures that any and all "verifications" required by governmental payers have been completed.
  • 1.5. Submits (using electronic systems or paper as applicable by payer) complete applications within thirty (30) days of notification of a new practitioner joining the network.
  • 1.6. Monitors on line or other sources on a continuous basis after submission to identify any outstanding items. Follows up on outstanding items to submit within five (5) business days.
  • 1.7. Perform ongoing research via running standard reports to validate that data is accurate and complete with no duplicate providers.
  • 1.8. Ensures that all required data fields are appropriately and accurately populated in MSOW.
  • 1.9. Enrolls practitioners in NPDB Continuous Query (Proactive Disclosure Service) and maintains enrollment in Proactive Disclosure Services (adding new and removing terminated practitioners accordingly and on a timely basis)
  • 1.10. Participates in credentialing committee meetings as necessary / instructed.
  • 1.11. Ensures that practitioners are enrolled (as evidenced by receipt of a provider number) with all relevant governmental payers within ninety (90) days of notification that a new practitioner has been contracted by the organization.
  • 1.12. Updates any internal tracking sheets with respect to status of enrollment as instructed.
  • 1.13. Coordinates with Network Credentialing Coordinator in the notification process to Corporate Billing Services representatives with provider identification numbers within three (3) business days of receipt of number.
  • 2. Completes maintenance updates and re-verification/re-validation for all practitioners within established timeframes.
  • 2.1. Maintains and updates data on practitioners including, but not limited to: name changes, office location and demographic changes, collaborating or supervising MD updates/changes, linking practitioners to new groups, TINs, etc.
  • 2.2. Participates in the onboarding and new practitioner conference calls or other communications/meetings along with Manager and other staff as applicable and is responsible for adding new practice locations to existing TINs for acquisitions or newly established practice addresses.
  • 2.3. Removes practice addresses which are no longer operational as applicable and upon definitive confirmation and reports removals appropriately based upon instruction.
  • 2.4. Complies with any other Federal or State requirements for maintenance of enrollment of practitioners including completion of re-validation requests. Ensures that correct addresses and contact information is identified for purpose of re-validation.
  • 3. Responsible for populating and updating MSOW Network Manager to accurately reflect commercial and non-commercial (government) payer participation and related data.
  • 3.1. Following each Credentials Committee meeting or approval of applicants by the Credentials Committee Chair; enters plans into MSOW including start date / effective date of each within three (3) business days or fewer.
  • 3.2. Completes data entry relative to other fields as instructed.
  • 3.3. Notifies Network Credentialing Coordinator when data has been populated so that notification can be provided to commercial payers under delegated credentialing agreements.

    Other information:


    Associate's Degree or equivalent experience preferred.


    Minimum of 2-3 years experience in non commercial payer enrollment.


    CPCS Certification preferred but not required.


    Evidence of outstanding attention to detail and ability to follow through and meet hard deadlines; ability to prioritize and organize multiple tasks concurrently without losing track of deadlines with significant independence; ability to remain organized with interruptions; ability to adapt to changing priorities; initiative to problem solve issues to resolution and remain persistent in order to accomplish goals; outstanding verbal and written communication skills; proficient in EXCEL, Word and Outlook. Ability to learn new software programs quickly; Basic math skills; outstanding customer service skills;

    Directly accountable for ensuring the successful and accurate completion of the enrollment process for all payers as instructed and within deadlines as expected; responsible for staying on top of and ahead of impending deadlines and anticipate issues and needs relative to payer enrollment to eliminate the opportunity for enrollment based claims denials.

    Not a traditional, straightforward enrollment position and interactions will cross a few areas within Yale New Haven Health. Individual must be able to think creatively and critically working with colleagues within the Medical Staff Administration Department to eliminate duplicative work for practitioners and to communicate with others in recruitment, HR and revenue cycle.

    Must be able to sit at a computer for extended periods of time; some light lifting and walking around the organization as needed to interact with others.

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    Job Info

    Job: 4230

    Department: Medical Staff Administration
    Category: Finance
    Shift: DAYS
    Hours: 40.00

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