What does a provider enrollment specialist do?
A provider enrollment specialist is in charge of handling application procedures in a company or facility. Their responsibilities typically revolve around gathering information, reviewing and verifying requirements, processing applications, and liaising with clients. They may also maintain and update databases, assist during complicated procedures, and ensure that all requirements are complete and accurate. Furthermore, as a provider enrollment specialist, it is essential to discuss terms and conditions to clients, helping them understand the company's policies and regulations, including its vision and mission.
Provider enrollment specialist responsibilities
Here are examples of responsibilities from real provider enrollment specialist resumes:
- 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.
- Provide daily support to the newborn enrollment functions, including call center request for verification and updates, also PCP assignments.
- Package confidential letters for mail processing following HIPAA guidelines
- Document communication meticulously and maintain confidentiality per HIPAA laws.
- Assist with the eligibility appeals process for deny attestations.
- Assist providers with completing CMS applications and verifies validity of supporting documentation.
- Communicate via telephone and written correspondence with insurance companies, patients and physicians.
- Assist with provider appeals, physician credentialing process and facility site-reviews when applicable.
- Verify hospitalization insurance coverage, compute patients' benefits and compile itemized hospital bills.
- Handle resolution/inquiries from members and/or providers that include benefit and eligibility information, verifying appropriate ICD-9 and CPT coding usage.
Provider enrollment specialist skills and personality traits
We calculated that 12% of Provider Enrollment Specialists are proficient in Data Entry, Patients, and CAQH. They’re also known for soft skills such as Business skills, Analytical skills, and Communication skills.
We break down the percentage of Provider Enrollment Specialists that have these skills listed on their resume here:
- Data Entry, 12%
Initiated data entry of provider-related demographic information changes and overseen testing and completion of change requests for the network.
- Patients, 12%
Handle confidential or sensitive information with discretion pertaining to all Providers and Medicare patients.
- CAQH, 9%
Submitted Texas Standardized Credentialing Applications for all providers not in the CAQH data base (Council for Affordable Quality HealthCare).
- Medicare, 7%
Processed Medicare applications for physicians/non-physicians.
- Medicaid, 7%
Examined, analyzed and interpreted a high volume of provider information to determine eligibility for acceptance as a Medicaid enrolled provider.
- Provider Enrollment Applications, 6%
Processed provider enrollment applications for CMS utilizing outlined guidelines within the Federal and State Programs regional requirements.
Common skills that a provider enrollment specialist uses to do their job include "data entry," "patients," and "caqh." You can find details on the most important provider enrollment specialist responsibilities below.
Business skills. To carry out their duties, the most important skill for a provider enrollment specialist to have is business skills. Their role and responsibilities require that "specialists must understand basic finance and accounting." Provider enrollment specialists often use business skills in their day-to-day job, as shown by this real resume: "verified and validated information on multiple systems and databases to comply with business requirements and ensure quality standards. "
Analytical skills. Many provider enrollment specialist duties rely on analytical skills. "compensation, benefits, and job analysis specialists perform data and cost analyses to evaluate their organization’s policies," so a provider enrollment specialist will need this skill often in their role. This resume example is just one of many ways provider enrollment specialist responsibilities rely on analytical skills: "conduct in-depth review and verification of provider data through information databases and contact with relevant organizations and agencies. "
Communication skills. This is an important skill for provider enrollment specialists to perform their duties. For an example of how provider enrollment specialist responsibilities depend on this skill, consider that "specialists need to provide information about compensation and benefits in a way that is understandable to employees at all levels throughout their organization." This excerpt from a resume also shows how vital it is to everyday roles and responsibilities of a provider enrollment specialist: "maintain continuous communication with providers regarding needed vital information and supply network provider data changes to other departments. ".
The three companies that hire the most provider enrollment specialists are:
- Public Consulting Group53 provider enrollment specialists jobs
- McKinsey & Company Inc44 provider enrollment specialists jobs
- Change Healthcare38 provider enrollment specialists jobs
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Compare different provider enrollment specialists
Provider enrollment specialist vs. Benefits advisor
A benefits advisor specializes in devising benefits programs and strategies for a workforce, ensuring they are well-compensated for their hard work. Typically, their responsibilities revolve around performing research and analysis to identify the needs of employees in a company, studying the benefit programs of competitors, and assessing the existing programs while putting the company's welfare into consideration. They must prepare reports and presentations for clients, provide cost-estimates and business plans, and evaluate risks, all while adhering to the company's policies and regulations, including its vision and mission.
These skill sets are where the common ground ends though. The responsibilities of a provider enrollment specialist are more likely to require skills like "data entry," "caqh," "medicare," and "provider enrollment applications." On the other hand, a job as a benefits advisor requires skills like "insurance benefits," "medicare advantage," "insurance products," and "health insurance." As you can see, what employees do in each career varies considerably.
Benefits advisors earn the highest salaries when working in the government industry, with an average yearly salary of $79,775. On the other hand, provider enrollment specialists are paid more in the technology industry with an average salary of $42,041.On average, benefits advisors reach similar levels of education than provider enrollment specialists. Benefits advisors are 1.5% more likely to earn a Master's Degree and 0.3% more likely to graduate with a Doctoral Degree.Provider enrollment specialist vs. Employee benefits supervisor
An Employee Benefits Supervisor supervises, trains, and completes performance reviews for the staff they manage. They develop and update procedure manuals, analyze, note down company operations, and interact with company vendors, staff, officials, members, and other entities. They oversee all open enrollment aspects with the help of employee wellness and communications or marketing staff. They also manage vendor performance, review service agreements, lead staff calls, meetings, and lead vendor calls.
Each career also uses different skills, according to real provider enrollment specialist resumes. While provider enrollment specialist responsibilities can utilize skills like "data entry," "patients," "caqh," and "provider enrollment applications," employee benefits supervisors use skills like "hr," "payroll," "customer service," and "hris."
Employee benefits supervisors earn similar levels of education than provider enrollment specialists in general. They're 0.9% more likely to graduate with a Master's Degree and 0.3% less likely to earn a Doctoral Degree.Provider enrollment specialist vs. Benefits representative
A benefits representative is responsible for facilitating and disseminating information about benefits programs and policies across all employees in the company. Benefits representatives respond to the employees' inquiries and concerns of benefits processes, update their benefits information, and resolve discrepancies and disputes. They also support the company's initiatives on developing new benefits plans, implementing campaigns, as well as writing application guides for reference. A benefits representative should have excellent communication and organizational skills as they also conduct surveys to check the efficiency and effectiveness of the benefits programs and adjusting procedures as needed.
Some important key differences between the two careers include a few of the skills necessary to fulfill the responsibilities of each. Some examples from provider enrollment specialist resumes include skills like "data entry," "caqh," "medicare," and "provider enrollment applications," whereas a benefits representative is more likely to list skills in "customer service," "insurance coverage," "term disability," and "health insurance. "
Benefits representatives earn the highest salary when working in the finance industry, where they receive an average salary of $41,460. Comparatively, provider enrollment specialists have the highest earning potential in the technology industry, with an average salary of $42,041.Most benefits representatives achieve a similar degree level compared to provider enrollment specialists. For example, they're 0.2% more likely to graduate with a Master's Degree, and 0.3% more likely to earn a Doctoral Degree.Provider enrollment specialist vs. Benefits assistant
Typically working in a human resources department, a benefits assistant is in charge of performing clerical support tasks for an efficient workflow. They primarily communicate with employees to answer inquiries regarding benefits and compensation programs, assist in processing documents, and resolve issues and concerns. Their responsibilities also include conducting research and analysis, liaising with external parties such as vendors and suppliers, organizing documents, and maintaining records. Above all, it is essential to carry out duties while adhering to the company's policies and regulations.
Types of provider enrollment specialist
Updated January 8, 2025
