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Credentialing Provider Enrollment Manager Jobs in Wisconsin

Armada Ltd

Credentialing Specialists

Milwaukee, WI · On-site

Credentialing Specialists will provide credentialing service and support to operate IRS ... View, manage, and check daily appointments in time trade scheduling tool Credentialing Specialists ...

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Credentialing Provider Enrollment Manager information

What is a credentialing provider enrollment manager?

A Credentialing Provider Enrollment Manager is a professional responsible for overseeing the process of verifying healthcare providers’ qualifications and enrolling them with insurance payers and government programs. They ensure that all providers meet the necessary standards and maintain compliance with regulatory and organizational requirements. Their role includes managing documentation, coordinating with providers and payers, and staying up to date with changes in credentialing and enrollment policies. This position is essential for healthcare organizations to ensure that providers are authorized to deliver services and receive reimbursement.

What are the key skills and qualifications needed to thrive as a credentialing provider enrollment manager, and why are they important?

To thrive as a Credentialing Provider Enrollment Manager, you need in-depth knowledge of healthcare regulations, credentialing standards, and provider enrollment processes, often supported by a bachelor’s degree in healthcare administration or a related field. Familiarity with credentialing software (such as CAQH or Verity), database management, and understanding of payer requirements are typically essential. Exceptional organizational skills, attention to detail, and strong communication abilities help in managing complex documentation and facilitating provider relations. These competencies ensure accurate, timely provider onboarding and regulatory compliance, which are critical for uninterrupted patient care and organizational success.

What are some common challenges faced by a credentialing provider enrollment manager, and how can they be addressed?

Credentialing Provider Enrollment Managers often encounter challenges such as managing tight deadlines for provider onboarding, navigating complex payer requirements, and ensuring compliance with ever-changing regulations. Maintaining clear communication with providers and payers, staying updated on industry standards, and implementing robust tracking systems can help address these issues effectively. Regular training for staff and fostering a collaborative team environment are also key strategies for overcoming these challenges and ensuring smooth enrollment processes.

What is the difference between Credentialing Provider Enrollment Manager vs Credentialing Specialist?

AspectCredentialing Provider Enrollment ManagerCredentialing Specialist
CertificationsOften requires industry certifications like CPCS or CPMSMMay hold certifications such as Certified Provider Credentialing Specialist
Work EnvironmentManages teams, oversees enrollment processes, interacts with payersPerforms credentialing tasks, verifies provider information, processes applications
Employer & Industry UsageUsed in healthcare organizations, insurance companies, and credentialing firmsCommonly employed in healthcare facilities, billing companies, and credentialing departments

The Credentialing Provider Enrollment Manager typically oversees the entire provider enrollment process, managing teams and strategic planning. In contrast, the Credentialing Specialist focuses on executing credentialing tasks and verifying provider credentials. Both roles are essential in healthcare credentialing but differ in scope and responsibilities.

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For Credentialing Provider Enrollment Manager jobs in Wisconsin, the most frequently searched job titles are:

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What cities in Wisconsin are hiring for Credentialing Provider Enrollment Manager jobs?

Cities in Wisconsin with the most Credentialing Provider Enrollment Manager job openings:

Credentialing Provider Enrollment Manager jobs near you

Provider Enrollment Credentialing Specialist

Dentaquest

Grafton, WI

Full-time

Re-posted 13 days ago

DentaQuest rating

5.2

Company rating: 5.2 out of 10

Based on 8 frontline employees who took The Breakroom Quiz

302nd of 315 rated insurance

Job description

Primary responsibilities include taking a new provider application from receipt to inclusion on directory along with ongoing updates. This includes accurate and timely entry of provider data including provider applications and contract information, status changes, payee changes, verifying all the credentialing criteria for practitioners that have applied to the network, including both initial and re-credentialing and follow up with practitioners as needed to obtain information for the credentialing process or as a result of mail being returned undeliverable to DentaQuest. 

JOB DUTIES AND RESPONSIBILITIES:

  • Enter and maintain Provider applications, contracts and updates into the system.
  • Enter and maintain all Provider information into credentialing database.
  • Verify potential and existing Provider’s licensure, liability insurance, BNDD, CDS and DEA certificate.
  • Verify Provider’s education, hospital privileges, Board certification and other criteria as required.
  • Verify accurate banking & billing information.
  • Perform ongoing research tocorrect data so it does not create duplicate provider, locations, payees, and participations.
  • Maintain credentialing information by reviewing, entering and following up on missing information.
  • Review National Practitioners Data Bank for adverse charges pending or filed against Provider.
  • Track contract applications status.
  • Assure all files have a Welcome, Denial or Term Letter as appropriate.
  • Meet required turnaround times and accuracy rates.
  • Maintain fee schedules by creating, reviewing and auditing provider fees.
  • Keep up to date provider enrollment process and records and track provider participation levels.
  • Facilitate provider related research based on suspended claims, PO returns and other feedback opportunities.
  • Participation in credentialing committee as necessary.
  • Update the system and the credentialing database to reflect approvals, denials and/ or terminations.
  • Assist with other duties as assigned.

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