Walk-in || Senior Provider Enrollment Specialist

Greetings from Sutherland!

The Provider Enrollment Specialist is a crucial part of the revenue cycle team, responsible for managing the end-to-end process of enrolling healthcare providers (physicians, clinics, facilities, etc.) with government and commercial insurance payers. This role ensures that providers are properly credentialed, actively participating in health plans, and eligible to receive timely reimbursement for services rendered. The specialist will serve as the primary liaison between providers, internal departments, and external payer organizations.

Essential Functions and Responsibilities

• Application Management: Prepare, submit, and track initial enrollment applications and re-credentialing paperwork for all providers across various commercial and government payers (Medicare, Medicaid, etc.).
• Documentation & Verification: Collect and verify all required documentation, including licenses, DEA numbers, NPI numbers (Type 1 & 2), board certifications, malpractice insurance, and CVs, ensuring all information is accurate and up-to-date.
• Payer Communication & Follow-up: Act as the main point of contact for insurance plans. Conduct timely and consistent follow-up via phone, email, and payer portals to monitor application status, resolve discrepancies, and expedite the receipt of provider numbers/effective dates.
• Database Maintenance: Accurately enter and maintain all provider demographic and enrollment data in the credentialing database (e.g., CAQH, PECOS, internal systems) to ensure data integrity and compliance.
• Problem Resolution: Troubleshoot and resolve complex enrollment-related issues, claim denials due to credentialing reasons, and other discrepancies that arise during the enrollment cycle.
• Compliance & Reporting: Ensure all enrollment activities comply with state, federal (CMS), and organizational regulations (e.g., NCQA). Generate status reports on application volume, approval rates, and processing timelines for management review.
• Process Improvement: Identify bottlenecks or inefficiencies in the enrollment workflow and collaborate with management to develop process improvements and standard operating procedures (SOPs)

Required Skills and Qualifications

• Experience : Minimum of 12 Months of direct, hands-on experience in provider enrollment & credentialing within a healthcare setting.

Note: Experience solely in member enrollment or Payer credentialing is not applicable to this role.

Knowledge:

• In-depth knowledge of Medicare, Medicaid, and commercial insurance carrier policies, procedures, and enrollment requirements.
• Familiarity with online provider databases and systems such as CAQH, PECOS, NPI registry, and state licensing boards.

HR Contact - [phone removed] - [email removed]

If you have relevant experience or know someone who is a good fit, share this opportunity with your network!

Note: "Sutherland never requests payment or favors in exchange for job opportunities. Please report suspicious activity immediately to [email removed]