Payer Enrollment Specialist

Job Description:

EDI Enrollment Management:

• Prepare, submit, monitor, and maintain EDI enrollment requests for electronic transactions, including:
  • Electronic Claims (837)
  • Electronic Remittance Advice (ERA/835)
  • Electronic Funds Transfer (EFT)
  • Claim Status transactions (276/277), where applicable
  • Eligibility transactions (270/271), where applicable
• Complete payer-specific electronic enrollment applications through payer portals, clearinghouses, and paper enrollment processes, as required.
• Coordinate EDI enrollments with clearinghouses and insurance payers to establish electronic connectivity for assigned providers and client groups.
• Validate provider demographic information, National Provider Identifier (NPI), Tax Identification Number (TIN), billing information, and banking details before submission to ensure enrollment accuracy.
• Track enrollment status, payer responses, effective dates, approvals, and activation milestones through completion.

Payer & Clearinghouse Follow-up:

• Perform timely follow-up with insurance payers and clearinghouses to obtain enrollment status, resolve deficiencies, and expedite approvals.
• Investigate and resolve rejected, delayed, or incomplete EDI enrollment requests.
• Escalate aging enrollments, payer delays, or connectivity issues that may impact claims submission or payment processing.
• Maintain consistent communication with internal stakeholders regarding enrollment progress, risks, and expected completion timelines.

Documentation & Quality:

• Maintain accurate documentation within enrollment systems, work queues, trackers, CMD records, and document repositories.
• Document payer communications, enrollment approvals, rejection reasons, and corrective actions in accordance with RCMS documentation standards.
• Ensure all enrollment records are complete, current, and audit-ready.
• Safeguard sensitive provider and banking information while adhering to HIPAA and organizational security requirements.

Cross-Functional Collaboration:

• Partner with Credentialing, Billing, AR, Payment Posting, Client Success, Implementations, and U.S.-based teams to support provider onboarding and revenue cycle readiness.
• Coordinate with internal departments to resolve enrollment dependencies affecting electronic claims submission or payment processing.
• Support new client implementations, provider onboarding, and organizational growth initiatives by ensuring timely EDI setup.
• Identify process improvement opportunities to reduce enrollment turnaround times, improve first-pass approval rates, and standardize EDI workflows.
• Assist in training team members and sharing payer-specific EDI enrollment knowledge and best practices.

Qualifacts is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.