Provider Enrollment Specialist
Job Description: The Insurance/Healthcare job family contains positions associated with providing consultancy utilizing knowledge and expertise on insurance and healthcare. Develops and implements general insurance and health policies in accordance with state and federal laws. Provides expertise to investigate and adjudicate claim characteristics that do not match policy provisions. Responds to provider appeals and meets with providers to resolve problems/issues. Provides directions for utilization review. Approves any remedial or recoupment actions associated with escalated claims. Advises provider review councils, state officials and works with organized healthcare groups and associations on various medical issues related to insurance and healthcare programs.
- Participates productively as member of team, possibly in a team lead role.
- Completes complex tasks, assignments and defined processes with some level of independence.
- Multiple assignments worked and completed simultaneously as directed by leadership.
- Identifies, prioritizes and resolves most questions and issues independently. Answers questions of peers. Escalates more complex questions or issues appropriately.
- Complies with contract requirements, business unit rules and related industry and legal regulations
Education and Experience:
- High School Diploma or equivalent; may hold 2 year post-high school Degree; may hold Bachelor’s degree.
- Typically, 2-4 years of working experience in related fields.
Knowledge and Skills:
- Office administrative experience and skills.
- Ability to follow written policies, procedures and guidelines, and give feedback to leadership.
- Intermediate-level knowledge of operating systems.
- Self-motivated with good time management and organizational skills.
- Ability to read and interpret basic to moderately complex documents such as operating and maintenance instructions, procedure manuals, and government/healthcare guidelines.
- Excellent written and verbal communication skills and customer service skills, including professional temlephone skills.
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