• Job Description

  Req#: PROVI002408

  1.0 FTE, 80 Hours Bi-Weekly
  Typically works standard business hours. Must be flexible for occasional meetings/assignments outside of standard business hours, may include occasional weekends.

  Position Overview:

  The Provider Enrollment Specialist is a complex position responsible for all aspects of provider and facility enrollment with health plans.

  Essential Duties & Responsibilities:

  • Coordinates, manages and communicates all aspects of provider and facility enrollment with Health Plans;
  • Knowledgeable and communicates health plan enrollment requirements;
  • Responsible for the submission of all provider information to health plans, as assigned or required by delegation agreements;
  • Responsible for the monthly provider sanction reviews;
  • The central point for provider and facility Health Plan enrollment inquiries from internal and external customers;
  • Acts as the back-up to the Medical Staff Services Specialist for all aspects of the credentialing process and assists to audit the credentialing process in accordance with NCQA standards;
  • Functional support for NCQA requirements and certifications;
  • Utilizes the electronic credentialing system, CAQH and PECOS for efficient submission of Health Plan enrollment applications;
  • Communicates with Health Plans to initiate, enroll, and credential providers by:
    • Compiling and researching provider licensing information
    • Completing appropriate application forms and providing required documentation/licensure to Health Plans
    • Communicating with providers and administration to ensure timeliness, promptness and accuracy in completion of enrollment/credentialing are proven and met
    • Follows up with Health Plans to ensure no lapse in coverage or need of further information by the Health Plan
  • Monitors current provider credentials with Health Plans to make sure all information is provided to Health Plans to ensure coverage for the providers is maintained and up-to-date for claims purposes;
  • Communicates to ancillary departments any important issues that may impact their areas pertaining to provider enrollment/credential approvals;
  • Actively engaged in ongoing continuous systems improvement to reduce waste and improve reliability of systems and processes within the scope of responsibilities;
  • Assists with ACO compliance requirements specific to Fraud, Waste and Abuse training for providers (including locums and independent contractors); and
  • Performs other duties as assigned.

  Skills and Experience:

  Required:

  • Basic computer skills (Word, Outlook, Patient information database (Cerner/EMR)
  • Possess strong verbal and written communication skills with the ability to clearly communicate with a variety of individuals.
  • Ability to complete work assignments and projects by deadlines; ability to work independently.
  • Possess a strong attention to detail.
  • Ability to track processes and follow up in a timely manner.
  • Possess proficiency with computer application, including, but not limited to Microsoft products and web-based systems.
  • Ability to use critical thinking skills.

  Preferred:

  • Knowledge of health plan policies, rules and regulations is preferred.
  • Associate's degree in a related field of study is preferred.
  • Experience in a related position and/or the healthcare industry is preferred.
  • Previous experience with provider and facility health plan enrollment is preferred.

  Physical Demands:

  Sedentary Work:

  Work activities that require lifting of objects up to 10-20# on rare to occasional basis. Sedentary work generally involves sitting most of the time, but may also involve walking or standing for brief periods of time. Roles are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

  Physical Requirements:

  • May complete computer work activities for the majority of the day with work tasks that require occasional standing to retrieve items from the other work spaces or use office equipment.
  • May assume reaching in vertical height within 20-35” on a regular basis and occasionally at 6-18” or at 40-60” when retrieving items from storage.
  • May bend from sitting or standing position to retrieve items from lower storage. Reaching in the front and to the side most often.
  • May use both hands to with simple grasping and pinch grasping to operate office equipment at desk heights.
  • May require light grip or pinch force with activities.
  • May handling office supplies that weigh less than 10# frequently such as reams of paper and rarely up to 15-20#

  Work Environment:

  Mobility is required. Light work with walking, sitting and standing.

  Required Work Schedule:

  Typically works standard business hours. Must be flexible for occasional meetings/assignments outside of standard business hours, may include occasional weekends.

  Summary of Benefits at Winona Health:

  At Winona Health, we are dedicated to offering a comprehensive and affordable benefits package for our employees and their families. While benefits may vary based on employment classification and job status, the following key benefits are available:

  Health Insurance: Options for medical, dental, and vision coverage, as well as mental health support and wellness incentives
  Income Protection: Short and long-term disability, plus additional benefits like accident, critical illness, hospital indemnity, legal assistance, and identity protection plans
  Retirement Planning: Access to a 403(b) retirement plan with employer contributions once eligibility requirements are met
  Work/Life Balance: Flexible scheduling, paid time off, and earned sick time to support personal well-being
  Education & Development: Paid training, tuition reimbursement, scholarships, and sponsored seminars to foster both personal and professional growth
  Employee Discounts: Special offers with local businesses, including the YMCA and cell phone providers

  For more details or specific information, visit our website or contact Human Resources

  Internal Applicant Policy:

  It is the policy of Winona Health to work with employees in an equitable fashion regarding promotions, transfers, and position reclassifications.
  
  Any employee wishing to apply for another available position at Winona Health must submit an application for consideration through the internal application portal. Employees requesting to change positions should have successfully completed at least six (6) months in their current position. Employees currently in the formal disciplinary process may be required to meet with the Director of Human Resources to determine eligibility to request transfer. The employee’s past performance, experience, training and qualifications will be considered in transfer/hiring decisions. Consideration for transfer or promotion is not a guarantee of transfer or promotion. Employees may be given a chance to interview for a position when they meet the minimum position qualifications.

  Disclaimer:

  Winona Health is an equal opportunity employer. Winona Health does not refuse to hire, discharge, or discriminate against a person with respect to tenure, compensation, terms, upgrading, conditions, facilities, or privileges of employment because of race, color, creed, religion, sex, age, national origin, marital status, genetic information, status with regard to public assistance, membership in a local discrimination commission, sexual orientation, disability, veteran status, or any other prohibited basis of discrimination under applicable local, state, or federal law. Winona Health does not tolerate retaliation against any employee, patient/resident, physician, or other individuals pursuing concerns regarding Civil Rights issues. Winona Health adheres to ALL pertinent governmental policies and legislation including the Civil Rights Act of 1964, Title VII, as amended, and the Minnesota Human Rights Act.

  Equal Opportunity Employer
  This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

• About the company

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