Job Summary
The Provider Enrollment Specialist is responsible for building and expanding PPO and specialty healthcare networks for a national managed care organization. This role includes initiating provider outreach, conducting presentations, negotiating reimbursement rates, and finalizing contracts with individual providers, ancillary facilities, and hospitals. The Specialist collaborates with internal stakeholders to identify market opportunities and develop strategic plans to enhance network adequacy and meet client needs.
Essential Duties and Responsibilities
- Align activities with the company’s mission, objectives, and operational strategy.
- Utilize contracting methodologies to build and maintain provider relationships.
- Initiate discussions and negotiations with healthcare providers to secure contracts and reimbursement schedules.
- Finalize agreements, amendments, and addenda with various provider types.
- Work closely with the VP of Network Development and marketing/contracting teams to ensure network adequacy.
- Renegotiate reimbursement rates with existing contracted providers as necessary.
- Process and review provider applications to ensure credentialing documentation is accurate and complete.
- Respond promptly to provider status inquiries via phone and email.
- Maintain accurate tracking of productivity and contract progress.
- Adhere to the organization’s Information Security Policies and HIPAA compliance standards.
Qualifications
- Minimum of 1 year of experience negotiating provider reimbursement rates (preferred, not required).
- Familiarity with CPT coding, Medicare RBRVS, ASC groupers, and per diem rate structures (preferred).
- Basic understanding of medical terminology (preferred).
- Strong verbal and written communication skills.
- Excellent organizational and time management skills.
- Professional appearance and demeanor.
Physical Requirements
- Must be able to operate standard office equipment (computer, telephone, copier, etc.).
- Ability to sit or stand for prolonged periods throughout the workday.
- Frequent computer/keyboard use (over ⅔ of the day).
- Visual acuity requirements include close vision, distance vision, and the ability to adjust focus.
- Frequent verbal communication and listening throughout the day.
Benefits:
- 401(k)
- 401(k) matching
- AD&D insurance
- Dental insurance
- Disability insurance
- Employee assistance program
- Flexible spending account
- Paid Sick Time
- Health insurance
- Life insurance
- Paid time off
- Parental leave
- Referral program
- Retirement plan
- Tuition reimbursement
- Vision insurance
Job Type: Full-time
Shift availability:
- Day Shift (Required)
Ability to Commute:
- West Lake Hls, TX 78746 (Required)
Work Location: In person
Skills Required
- Strong verbal and written communication skills
- Excellent organizational and time management skills
- Professional appearance and demeanor
- Ability to operate standard office equipment
- Ability to sit or stand for prolonged periods
- Frequent computer and keyboard use
- Frequent verbal communication and listening
- At least 1 year of experience negotiating provider reimbursement rates
- Familiarity with CPT coding, Medicare RBRVS, ASC groupers, and per diem rate structures
- Basic understanding of medical terminology
- Availability for day shift
- Ability to commute to West Lake Hills, Texas
What We Do
USA Managed Care Organization (USA MCO) is the largest, most comprehensive, privately-held Preferred Provider Organization in America, specializing in workers' compensation medical care and rehabilitation, and offering innovative alternatives to traditional group health and workers’ compensation medical benefits.
