As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own.
The Provider Enrollment Specialist performs administrative and technical duties requiring accuracy and attention to detail in the enrollment and re-enrollment of our organization and its healthcare providers with all managed care networks and government payors [Networks] the organization is contracted with, or has an agreement with, for the reimbursement of services. This position has continuous contact with internal and external customers including physicians and other healthcare providers, administrators, support staff and network representatives. Additionally, this position is responsible for communicating provider participation information to stated internal and external customers through established processes to allow for appropriate patient scheduling and reimbursement for services rendered. This position requires a comprehensive understanding of all system applications used in the division, must be able to identify application related problems and assist in resolving. Position assists in creating documentation, testing and maintenance of all system applications.
Accurately complete the enrollment/reenrollment processes as outlined by each network/area for all appropriate healthcare providers as identified through department policies and network reimbursement and delegated contracts to ensure timely and continued provider network participation.
Maintain detailed provider enrollment files in electronic format, including electronically received documents and scanning of hardcopy documents, and document each stage of enrollment/reenrollment process thoroughly.
Accurately maintain all internal systems with appropriate provider and network participation information. Systems including, but not limited to, Qlikview, Epic, Echo, PET and IGUIDE.
Develop and maintain good working relationships with Nemours providers and support staff to obtain necessary and timely information to facilitate the provider enrollment/reenrollment process.
Develop and maintain relationships with Network Representatives in order to facilitate the provider enrollment/reenrollment processes.
Performs follow up with health plans in order to expedite participation approval by each health plan.
Responds to and resolves problems with provider network participation as it relates to denial of services or reimbursement by working closely with all levels of administrative and clinical personnel and network representatives.
Responsible for educating providers, administrators and support staff regarding the enrollment/reenrollment processes and how it relates to the provider’s ability to provide care to network members in order to increases reimbursement and reduce patient dissatisfaction.
Work collaboratively with fellow team members to create, evaluate and maintain department workflows, processes, policies and systems.
Additionally, each team member is expected to cross train on location and provider type requirements to assist one another in completing assigned duties as the enrollment cycle warrants including special projects.
Adheres to Nemours Policies and Standards of Behavior.
Complies with HIPAA Privacy Regulations
Complies with OSHA/Safety Regulations.
Assists Supervisors and Manager to ensure team is utilizing resources efficiently and effectively.
All other duties and projects as assigned.
6 months to 1 year of Provider Enrollment experience preferred.
High School diploma required. Associate's degree preferred.
Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.
Nemours is committed to improving the health of children. As a non-profit children’s health organization, we consider the health of every child to be a sacred trust. Through family-centered care in our children’s hospitals and clinics in Delaware, New Jersey, Pennsylvania and Florida, as well as world-changing research, education and advocacy, Nemours fulfills the promise of a healthier tomorrow for all children — even those who may never enter our doors. Nemours began more than 70 years ago with the vision of Alfred I. duPont to improve the lives of children and to do whatever it takes to prevent and treat even the most disabling childhood conditions. Today, through our children’s hospitals and health system, we directly care for 250,000 children annually in Delaware Valley and Florida, including families who travel from across the country and world to see our specialists — treating every child as we would our own. We also reach beyond the walls of our hospitals and clinics to be a voice for children on a national and international level, and to lead the way in prevention, intervention, education, and research. Nemours is growing to better serve the children and families in our ca...re. We have 1.1 million square feet of space currently devoted to providing children’s healthcare or under construction, all designed with significant input and advice from our patients and families.