Verification specialist vs provider enrollment specialist

Differences between verification specialist and provider enrollment specialist duties and responsibilities

Verification specialist example responsibilities.

• Manage the TRICARE information program by presenting information utilizing available media, group presentations, or mailings.
• Maintain confidentiality of all patient medical information adhering to HIPPA regulations and Medicare / Medicaid policies.
• Verify primary insurance eligibility by phone with agents or online regarding Medicaid recipients and to determine payment responsibilities to providers.
• Verify medical coverage and benefits to providers and members, review certain ICD9 and CPT codes.
• Verify patient effective date of insurance, including CPT and diagnosis codes and general policy information.
• Receive extensive training on insurance plans and types, HIPAA compliance, PatientPlus programming and other workplace relate topics.
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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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