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

Job roles

  • 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

Education/certifications/licenses/registrations

  • 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
  • High school graduate or GED equivalency required

Experience/specialized skills (including language)

  • 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

Summary

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.

Education requirement

  • Bachelor’s Degree preferred but not required

Experience requirement

  • 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

Knowledge/skills/abilities

  • 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

Physical demands/conditions

  • 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

Job summary:

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/skills/abilities:

  • 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

Required education/experience:

  • 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.

LocationSalary LowSalary High
Phoenix, Arizona$38,300$51,800
Los Angeles, California$43,200$58,450
Denver, Colorado$36,000$48,700
Washington, DC$43,850$59,350
Miami, Florida$35,850$48,500
Orlando, Florida$33,050$44,700
Tampa, Florida$33,400$45,150
Atlanta, Georgia$35,000$47,350
Chicago, Illinois$40,250$54,450
Boston, Massachusetts$43,500$58,900
Minneapolis-St. Paul, Minnesota$34,700$46,950
New York City, New York$45,800$62,000
Philadelphia, Pennsylvania$37,300$50,450
Dallas, Texas$36,350$49,150
Houston, Texas$36,000$48,700
Seattle, Washington$41,900$56,650
National Average$32,750$44,300

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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