Provider Enrollment Specialist (51920)

POSITION SUMMARY
The Provider Enrollment Specialist is responsible for coordinating and managing all aspects of provider and facility enrollment, revalidation, credentialing support, and payer participation activities for physicians, advanced practice providers, and other healthcare professionals within the Critical Access Hospital (CAH). This position ensures timely enrollment and maintenance of provider records with Medicare, Medicaid (AHCCCS), commercial insurance carriers, and other third-party payers to support compliant billing and reimbursement.

The Provider Enrollment Specialist collaborates with medical staff, administration, revenue cycle, compliance, and payer representatives to ensure providers are credentialed, enrolled, and reimbursable in accordance with federal, state, and organizational requirements.

CORE FUNCTIONS

1. Manage provider enrollment with Medicare, AHCCCS, commercial insurance plans, and other third-party payers.
2. Prepare, complete, and submit enrollment applications accurately and within required timelines.
3. Coordinate provider revalidations, reenrollments, and updates to ensure uninterrupted participation with payers.
4. Maintain provider demographic information across all payer, regulatory, and organizational databases.
5. Monitor application status and proactively follow up with payers to resolve delays, deficiencies, and denials.
6. Serve as the primary liaison between providers, hospital departments, and insurance carriers regarding enrollment matters.
7. Maintain provider and facility records and credentialing files, ensuring all required documentation is complete, current, and audit-ready.
8. Verify and track provider licenses, certifications, DEA registrations, NPIs, and malpractice coverage to support enrollment and compliance requirements.
9. Utilize enrollment and credentialing systems including CAQH, PECOS, NPPES, and payer-specific portals.
10. Support new provider onboarding by coordinating enrollment activities to ensure timely billing readiness and payer participation.
11. Research and resolve enrollment-related billing issues that impact reimbursement and revenue cycle performance.
12. Ensure compliance with CMS, AHCCCS, CAH Conditions of Participation, HIPAA, and organizational policies.
13. Generate and maintain reports regarding provider enrollment status, pending applications, expirations, and payer participation.
14. Collaborate with Revenue Cycle, Medical Staff Services, Human Resources, Compliance, and Administration to support provider practice operations and reimbursement objectives.
15. Participate in audits, process improvement initiatives, and regulatory reviews to enhance enrollment accuracy, efficiency, and compliance.

PHYSICAL DEMANDS/ENVIRONMENT FACTORS
Able to stand, walk, bend, squat, reach, and stretch frequently.
Possess physical agility and adequate reaction time to respond quickly and appropriately to department needs.
Needs adequate hearing and visual acuity, including adequate color vision.
Requires fine motor skills, adequate eye-hand coordination, and ability to grasp and handle objects.
May be required to lift up to 50 pounds.
Must use standard precautions due to threat of exposure to blood and bodily fluids.
Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
May require periodic use of personal computer.

MINIMUM QUALIFICATIONS
High School Diploma or General Education Diploma (GED) required.

1–2 years of experience in provider enrollment, credentialing, medical staff services, revenue cycle management, billing, or payer relations.

Basic knowledge of provider enrollment and credentialing processes. Understanding of Medicare, Medicaid/AHCCCS, and commercial payer requirements. Knowledge of healthcare regulatory and compliance standards, including HIPAA.

Familiarity with CAQH, PECOS, NPPES, and payer enrollment portals preferred.