Healthcare Enrollment Specialist How to Hire, Salary Data, and Job Descriptions
Healthcare enrollment specialists determine the type of care for which patients in a clinic or hospital are eligible. They also verify patient’s eligibility with their insurance carrier, collect health records, and manage medical care forms. Health insurance companies also employ enrollment specialists. In that setting, they assist customers with enrolling in healthcare programs, answer questions about benefits, and maintain current customers.
Healthcare enrollment specialists need to possess administrative and organization skills and communication and customer service skills. Candidates should also be well-versed in all aspects of the programs for which they enroll customers and patients so that they can pass along accurate information.
Sample job description #1
Conducts health insurance options education at appropriate agency and community sites. Attends community meetings and trainings as needed
Documents contacts, maintains files, and submits program statistics as needed. Utilizes an enrollment verification system to document outcomes. Timely and complete submission of project logs/data reports
Meets department application assistance productivity standards of 4 applications per day
Performs other duties as assigned
Provides health insurance eligibility determination and application assistance at assigned clinic and community sites
Ability and means to travel as needed in a timely manner within (City) County, to locations that may have limited access to public transportation; proof of liability and property damage insurance on vehicle used is required
Certified Enrollment Counselor Certification must be obtained within 90 days of hire and maintained while in this position
Ability to work effectively with other organizations
Ability to work effectively with patients from diverse social, cultural, and economic groups
Ability to work independently and use critical thinking skills
Basic knowledge of Medi-cal, Medi-Cal Managed Care Plans, Covered California, CalFresh, and private insurance
Bilingual in English/Spanish required
Excellent interpersonal and customer service skills
Intermediate Written and verbal communication skills
Sample job description #2
The Payor Credentialing and Enrollment Specialist will accomplish the following functions for billable employed physicians, allied health professionals, or contracted providers associated with ABC Company.
Bachelor’s Degree preferred but not required
Minimum of 3 years-experience in a healthcare environment with direct related credentialing or payor enrollment experience required
Ability to master and employ a variety of complex procedures, methods, and processes to perform provider credentialing and enrollment functions
Knowledge of NCQA/URAC standards preferred
Knowledge of Joint Commission standards preferred. Knowledge of on-line enrollment systems such as PECOS and credentialing database such as ECHO and/or Symed
Key job responsibilities
Initiate and maintain ABC Company hospital credentialing for all providers in the group
Initiate and maintain payor enrollment for providers
Facilitate other hospital and/or facility membership for group providers as indicated
Prepare initial credentialing and recredentialing files to be presented to the Credentialing Committee in a timely and expeditious manner
Initiate and maintain provider payor enrollment as assigned
Ensure accuracy and completeness of provider applications whether paper or electronic
Complete and maintain CAQH profile for all assigned billable providers including re-attestation every 90 days
Provide regular updates to the payors of changes in billable provider demographics, practice locations, name changes, etc.
Prepare reports of provider data for distribution to internal and external customers
Monitor expirables including license, DEA, board certification, malpractice, and provide current copies to all payors at the time of renewal
Maintain accurate and concurrent updates and tracking for each provider to reflect the history of a provider’s credentialing and enrollment status
Resolve complex issues relating to provider credentialing
Respond to requests by external and internal entities regarding issues pertaining to the status of credentialing and/or enrollment of providers
Accurately completes applicable facility (hospital, surgical centers, etc.) applications for signature by affected provider
Follow up with facility routinely to ensure information is complete and accurate and that the facility is aggressively processing the application
Prepare facility recredentialing applications on all assigned providers
To model ABC Company’s mission and values at all times
Problem solving skills and ability to explore all options and use available resources to find new and effective solutions
Strong organizational, critical thinking, and problem-solving skills required
Ability to communicate appropriately and effectively with providers; including sensitive and confidential information
Must be able to prioritize and meet deadlines on an ongoing basis to ensure timely completion according to process requirements
Exhibits sound judgment and one who hold themselves up as a role model and mentor
The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion
Must have good balance and coordination
The physical requirements of this position are: light work – exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently
The employee is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures, transcribing, viewing a computer terminal, or extensive reading
The conditions to which the employee will be subject in this position: The employee is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work
Sample job description #3
The Provider Enrollment Specialist is responsible for coordinating, monitoring, and maintaining the provider enrollment and re-enrollment process in a timely and compliant manner with all government and commercial payors. Facilitates all aspects of provider enrollment, including initial enrollment, re-enrollment, monitoring, and appointment for the medical staff and allied health practitioners. Assists with problem identification and timely resolution of payor related issues surrounding claim submission and denial management to ensure optimal reimbursement. Position serves as the liaison between managed care plans and ABC Company, including Revenue Cycle Operations and the Faculty Group Practice, to resolve any billing issues related to provider enrollment and promote optimal reimbursement.
Essential job functions:
Facilitate enrollment of new ABC Company providers to ensure proper and timely billing and collections
Prepare enrollment applications for all health plans including Medicare and Medicaid
Complete data entry and processing of enrollment applications, with validation of provider submitted information to ensure the application is complete, accurate, and meeting ABC Company standards
Obtain licensure, certification, and insurance certificates at time of enrollment and maintain in database in order to submit with enrollment applications
Maintain timelines on enrollment processes, and address and/or escalate any delays
Ensure that all pending enrollments are reviewed, obtained, and managed according to the rules and policies of the department
Provide monthly notification of new providers, resignations, and changes in provider status such as practice locations and panel status to contracted plans
Follow up with necessary contacts, including providers and managed care organizations, to resolve enrollment application issues and deficiencies
Facilitate resolution of provider related denials to ensure appeal procedures are followed to result in proper reimbursement
Demonstrate a level of competence and understanding of all state and federal laws, rules and regulations according to payer guidelines for billing
Respond to internal and external inquiries on routine enrollment and contract matters, as appropriate
Perform detailed follow-up activities on assigned accounts according to procedures
Resolve outstanding AR accounts at a defined level of productivity
Maintain confidentiality of all provider enrollment business/work and medical staff information
Marginal or periodic job functions:
Prioritize and complete all work in an accurate, effective, and efficient manner
Participate in team meetings/activities and support the philosophy and goals of the team and department
Participate in special projects/assignments
Read all announcements and relevant communications relating to job duties
Successfully complete competency based training and testing
Perform related duties as required
Knowledge of insurance claim processing and third party reimbursement
Knowledge of state and federal regulations as they pertain to billing processes and procedures
Ability to understand and interpret statistical reports and perform quantitative analysis
Knowledge of the principles of Information Systems in order to effectively analyze and make decisions, preferably with experience in Epic and database management
Skill in effective oral, written, and interpersonal communication
Skill in time management and project management
Ability to work efficiently under pressure
Ability to operate a computer and related applications
Ability to work independently and take initiative
Ability to demonstrate a commitment to continuous learning and to operationalize that learning
Ability to deal effectively with constant changes and be a change agent
Ability to deal effectively with challenging situations
Ability to willingly accept responsibility and/or delegate responsibility
Associate’s Degree or equivalent and three years of financial, credentialing, billing, or related experience in a healthcare organization
Average salary and compensation
The average salary for a healthcare enrollment specialist is $38,500 in the United States. Position salary will vary based on experience, education, company size, industry, and market.
Los Angeles, California
Minneapolis-St. Paul, Minnesota
New York City, New York
Sample interview questions
Do you have any experience as an enrollment specialist?
Do you have any experience in the medical field?
Do you have good communication skills?
Do you understand how to use data entries?
Are you familiar with data entry?
Have you worked with healthcare benefits in the past?
Can you understand and remember procedures, prices, regulations, etc.?
Would it trouble you to have to deal with an upset or possibly angry client?
What if someone doesn’t qualify for the specific plan you had in mind but they can’t afford the one they do qualify for? How would you remedy this?
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