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Manage analytics and deliverables with Health Plan and Government payers as required by the Commercial payers, Centers of Medicare & Medicaid Services (CMS), Department of Health (DOH) for Quest Diagnostics, its subsidiaries, affiliates, and their respective testing facilities. Drive process compliance, controls and standardization utilizing a Centers of Excellence methodology to support all reporting analytics and Provider Enrollment activities.
- Engage with federal & state government and third-party payers on current and future regulatory requirements
- Create and manage central repository of key reference information regarding provider application requirements
- Develop and manage reporting for provider enrollment activities
- Engage with Compliance, Legal, Laboratory Operations, Optum, Risk Management, Health Plans, and Business Development on strategic initiatives, federal and state requirements for enrollment, and other payer requests
- Create and update SOPs and playbooks to ensure that processes are aligned with the Centers of Excellence key business objectives, government, and industry standards
- Complete requests for federal & state government and third-party payers to include completion of, but not limited to, provider enrollment applications, revalidation requests, NPI enrollments, third-party payer credentialing and attestations
- Train team members on changes in enrollment requirements
- Perform Quality Assurance/Quality Control (QA/QC) on team enrollment and credentialing submissions
- Perform thorough credit evaluations to assess financial risk of customers, ensuring compliance with company's credit policies and guidelines
- Distribute monthly rosters of patient-facing facilities to ensure accuracy in various third-party payer directories
- Govern and distribute a catalogue of all testing facilities for the purpose of internal analytics that is used for contract negotiations and engagement with third-party payers
- Manage the updates of the online registry for commercial payers including their contractual status with Quest Diagnostics, its subsidiaries, and affiliates
Education:
- Bachelor's degree in business administration (preferred), Certification or equivalent
Required WorkExperience:
- 5+ years' relevant experience, including working knowledge of Medicare and Medicaid provider network requirements, enrollment, or third-party payer credentialing
- 5+ years' experience in Lab Industry and/or Healthcare industry and a comprehensive understanding of highly matrixed organizational structures
Preferred Work Experience:
- Work experience in Provider Enrollment and Credentialing including understanding of state regulatory requirements for Enrollment submission
Knowledge:
- Medicare Provider Enrollment, Chain, Ownership System (PECOS)
- State Medicaid Web Portals
- Council for Affordable Quality Healthcare (CAQH) Provider Daily Portal
- National Plan and Provider Enumeration System (NPPES)
- Salesforce.com or comparable CRM Tool
- Credentialing Software
Skills:
- Strong analytical and critical thinking skills
- Strong written and verbal communication
- Process planning and organization
- Strong technical skills in MS Word and Excel
- Able to multi-task and perform in a fast-paced environment
Equal Opportunity Employer: Race/Color/Sex/Sexual Orientation/Gender Identity/Religion/National Origin/Disability/Vets or any other legally protected status.
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Quest Diagnostics Incorporated
May 16, 2025