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Entity: Corporate Services
Department: Medical Affairs - Admin
Location: 3535 Market Street
Hours: Remote, M-F, daylight
Summary:
The Payer Enrollment Edit Analyst has overall responsibility for resolving enrollment edits having underlying issues attributed to OMA. Performs analysis to determine the underlying cause, and determines the appropriate resolution a) by the Specialist, b) by triaging to another Enrollment staff member based upon their responsibilities, or c) by communication with responsible clinical department staff who typically must make claim corrections. Enrollment edit resolution directly impacts the ability of UPHS to bill for services rendered by health care providers thereby directly impacting UPHS revenue generation. Enrollment edits typically range between $2-8M at any point in time, representing aging, unbillable claims.
In addition, the Specialist is the first point of contact for Penn Medicine in providing front-line diagnosis and support for all submissions to the Provider Credentialing Management System (application request system) as it relates to the enrollment of billable providers. Related responsibilities include working closely with the various IT teams within UPHS on systems and issues as they relate to enrollment.
Accountabilities

• Provider/Department Service:
• Works with the Epic Team, OMA IS Team, department, and Professional Billing Office to ensure that accurate provider, plan and practice information is maintained in Echo and the Edit Data System.
• First point of contact for Penn Medicine in providing front-line diagnosis and support for all submissions to the Provider Credentialing Management System as it relates to the enrollment of billable providers.
• Provider Enrollment/Analysis/Data Management:
• Handles intake, assessment and approval of all daily enrollment requests, both through the OMA Applications Request system and directly from departments.
• Works with the departments, providers and other OMA staff to ensure correctness and completeness of requests so that claims will ultimately be paid by payers in a timely and accurate manner. Enrollment requests include new practice set-up, and provider-specific transactions (initial enrollment, changes and terminations).
• Resolves issues causing enrollment edits so that claims are released to health plans for payment before timely filing limits prevent UPHS from collecting payment. Primarily responsible for edit types designated "OMA Edits" (currently 10 types), but also serves as a department resource for resolution of edit types designated "Department Edits" (currently 8 types).
• Working with Epic team, maintains the OMA/Epic provider enrollment interface which communicates provider enrollment status to Epic so that claims being held may be released for payment before timely filing limits prevent UPHS from collecting payment (this is one type of "OMA Edit" discussed more generally above).
• Monitors and reports enrollment edit trends and issues to the Manager and/or appropriate Enrollment Coordinator as they relate to aging and other management reports.
• Identifies and facilitates in a timely manner the correction of discrepancies that are preventing practitioners from being submitted on the next available monthly health plan exports for enrollment.
• Generates monthly termination reports for the enrollment coordinators to distribute to each payer to ensure the payer rosters correctly reflect UPHS provider information.
• Responsible for maintaining health plan application templates in the enrollment system.
• Responsible for identifying enrollment system issues and coordinating issues identified by other enrollment staff for resolution.
• Works closely with Sr. Manager to create and complete work orders through JIRA system.
• Notifies/educates staff regarding changes to the enrollment system/processes.
• Maintains proficiency in the utilization of enrollment databases.
• Run reports to support the provider enrollment process.
• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures
• Other duties as assigned to support the unit, department, entity, and health system organization

Minimum Requirements
Required Education and Experience

• H.S. Diploma/GED and 4+ years Proven experience in payor enrollment or credentialing or healthcare or insurance industry or project leadership

Or

• Bachelor's Degree and 2+ years Proven experience in payor enrollment or credentialing or healthcare or insurance industry or project leadership
• 1+ years Leadership experience (team lead, project lead, supervisor, etc.)
• 2+ years Previous/current experience as a CVO Enrollment Coordinator or equivalent

We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives.
Live Your Life's Work
We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.