Payer Activation Specialist

• Coordinates all application processes (application completion, provider communication, Epic provider set-up, etc.) regarding enrollments for Medicare, Railroad Medicare, Tricare, and Medicaid for professional providers and communicates all updates to appropriate areas.
• Responsible for maintaining knowledge of enrollment rules/forms/processes for National Provider Identifier (NPI), Medicare, Railroad Medicare, Tricare and Medicaid (including other state programs) for all provider types.
• Responsible for maintaining all expiration dates for all providers enrolled. Maintains enrollment and re-validation process. Maintains providers folders/files containing provider enrollment documents, signatures and forms while maintaining strict confidentiality.
• Collaborates with providers to apply for an NPI and perform updates/corrections on the National Plan and Provider Enumeration System (NPPES).
• Plans key communication with clinic operational leadership, provider affairs, managed care and credentialed verification team to ensure there are no lapses in provider enrollment that would result in loss of revenue.
• Serves as an expert to the hospital-based clinics, medical groups sites, revenue-producing hospital departments, third party payers, and other Revenue Cycle teams regarding enrollments and enrollment-related issues.
• Responsible for activating and maintaining all provider enrollment tables within Epic to ensure claims are released to the payers only once provider credentialing/enrollment finalized. Coordinates the resolution of claim edits related to NPI, CLIAs, tax IDs, and provider enrollment table.
• Acts as a liaison between clinic operational leadership and Advocate Physician Partners (APP) and the Center for Practitioner Information (CPI).
• Coordinates the resolution of denials related to enrollment issues. Collaborates with Advocate Physician Partners (APP) and the Center for Practitioner Information (CPI) on the resolution of denials related to non-credentialed providers. These denials occur from breakdown of communication of provider information between insurance carrier and Advocate Health Care.

Licensure, Registration, and/or Certification Required:

• None Required.

Education Required:

• High School Graduate.

Experience Required:

• Typically requires 5 years of experience in working with an automated patient accounting system.

Knowledge, Skills & Abilities Required:

• Strong understanding of governmental and insurance carrier credentialing process for providers and facilities.
• Knowledge of current Medicare/Medicaid payor guidelines and requirements.
• Strong analytical, organizational, and communication skills essential.
• Must have ability to function in a multi-disciplinary environment.

Physical Requirements and Working Conditions:

• Must be able to sit for extended periods of time.
• Position requires travel; therefore, incumbent may be exposed to road and weather conditions.
• Generally exposed to a normal office environment.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.