Provider enrollment specialist vs enrollment representative

Differences between provider enrollment specialist and enrollment representative duties and responsibilities

Provider enrollment specialist example responsibilities.

• Manage federal and state-mandate physician credentialing activities; act as NCQA committee liaison.
• Provide enrollment counseling to eligible recipients about Medicaid manage care and promote their voluntary enrollment into an HMO.
• Review provider enrollment applications to ensure the credentials and licenses meet all requirements for participation in the Medicare program.
• Verify provider is eligible to participate in Medicare according to CMS guidelines.
• Verify claim information using ICD-9 and medical terminology and CHAMPUS/ TRICARE guidelines .!
• Complete require forms and application for changes or updates in billing systems including EFT and or notification of Athena.
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Enrollment representative example responsibilities.

• Achieve excellent customer satisfaction ratings as documented by CIGNA surveys.
• Audit all tickets for proper labs, correct ICD-9 coding and CPT coding.
• Learned ICD-9 codes and medical billing to insure prompt and accurate processing of claims.
• Resolve claims by verifying CPT and ICD-9 coding and the expected reimbursement per contractual agreements with varying insurance providers.
• Proofread any errors than may occur, fax, file, track all PCP forms
• Adhere to all key audit controls and comply with all establish standards associate with HIPAA, SOX and SAS70.
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