Provider relations specialist vs provider enrollment specialist

Differences between provider relations specialist and provider enrollment specialist duties and responsibilities

Provider relations specialist example responsibilities.

• Design short and long term plans for PCPs to accomplish suggest benchmarks and growth of its membership.
• Provide keen oversight in developing and maintaining quality improvement programs while managing payroll.
• Organize and analyze CMS changes for distribution to the team.
• Meet or exceed productivity and quality goals base on CMS guidelines/directives.
• Establish and maintain positive and productive relations with network providers for Medicaid and Medicare.
• Assist in IPA profitability through the recruitment and contracting of key physicians, hospitals and ancillary organizations with target membership panels.
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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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