Payor Audit & Enrollment Specialist

Overview

The Specialist – Payor Audit & Provider Enrollment serves as the organization's subject-matter expert for payor audit response, delegated credentialing oversight, and provider enrollment data integrity. This role manages payor-initiated audits from intake through resolution, determining response strategy and authoring formal responses on behalf of the organization; leads delegated credentialing audits and maintains continuous audit readiness against payor and accreditation standards; and governs provider enrollment and billing data within DentalXchange and connected systems. Working under general direction, the Specialist interprets payor contracts, delegation agreements, and regulatory requirements, exercises independent judgment in assessing and escalating compliance and revenue risk, and develops the policies, controls, and reporting that govern these functions. The position advises Credentialing, Compliance, and Revenue Cycle leadership, partners across practice operations and billing, and provides technical guidance and mentorship to credentialing and enrollment staff.

Responsibilities

Payor Audit Strategy, Response & Risk Mitigation• Serve as the organization's subject-matter expert and point of contact for payor-initiated audits arising from patient complaints, billing concerns, quality-of-care allegations, and grievances, coordinating with the Credentialing Manager, who retains overall accountability for audit representation.• Independently evaluate each audit request to determine scope, exposure, and response strategy; design and administer the centralized audit intake, risk-tiering, and tracking framework.• Analyze practice, billing, and clinical records to construct the factual record supporting each response, then author and submit formal written responses to payors, exercising judgment on positioning, disclosure, and remediation commitments, and engaging Legal, Clinical, or Compliance partners where warranted.• Negotiate response timelines and extension requests with payor audit and network management contacts, and escalate matters of material risk — network sanctions, termination exposure, repeat findings, or systemic patterns — with a recommended course of action to the Credentialing Manager, Compliance, and operations leadership.• Analyze audit outcomes, root causes, and turnaround performance; translate findings into recommendations for provider education, workflow redesign, and policy change.Delegated Credentialing Oversight & Audit Readiness• Own the organization's delegated credentialing audit program, interpreting each delegation agreement and translating payor-specific obligations into internal standards, controls, and monitoring routines.• Lead the technical execution of pre-delegation and periodic delegated audits, serving as the lead technical representative to health plan delegation oversight teams in coordination with the Credentialing Manager.• Conduct internal file audits and mock audits against NCQA/URAC-aligned and payor-specific standards, determining where remediation is required, and draft or update credentialing policies, procedures, and committee documentation to maintain continuous audit readiness.• Draft and recommend corrective action plans in response to audit findings, defining root cause, remediation approach, ownership, and completion criteria for Credentialing Manager review and approval; drive approved plans to closure and validate sustained correction, while advising Credentialing and Compliance leadership on delegation risk and evolving accreditation or payor standards.Provider Enrollment & Clearinghouse Data Governance (DentalXchange)

 

Serve as system subject-matter expert and data owner for provider enrollment information within DentalXchange, establishing the data standards, validation rules, and audit controls that govern it.• Define and maintain the end-to-end enrollment workflow connecting credentialing, contracting, and clearinghouse activation, including service-level expectations and hand-off criteria across departments.• Design and perform recurring data integrity reviews reconciling demographic, NPI, tax ID, and enrollment data against source credentialing records, and diagnose complex enrollment rejections, payor edits, and connectivity failures, distinguishing isolated errors from systemic defects.• Serve as the designated system owner for the DentalXchange platform relationship, managing support escalations and configuration coordination (contracting and SLA management remain with the Credentialing Manager), and establish controls ensuring provider status changes — terminations, location/name changes, re-credentialing — are reflected accurately and timely across all connected systems.Billing Data Integrity & Revenue Protection• Define the record-keeping standards and reconciliation cadence required to support clean claims submission and continuous audit readiness across all practice locations.• Reconcile payor enrollment and effective-date records against credentialing and contracting status, identifying gaps that create denial or take-back exposure before claims are submitted.• Analyze denial and rejection trends attributable to enrollment or credentialing defects; quantify financial impact and recommend corrective process or system changes, maintaining the documentation architecture (fee schedules, enrollment confirmations, EDI/ERA records) supporting billing-related audit responses.• Partner with Billing and Revenue Cycle leadership to prioritize remediation for providers or locations at risk of billing disruption, and advise on go-live readiness for new providers and acquired practices.Program Governance, Reporting & Continuous Improvement• Build and maintain the reporting package for payor audit volume, outcomes, cycle time, delegated audit results, and enrollment data quality; present findings and recommendations to the Credentialing Manager, Compliance, and Revenue Cycle partners.• Recommend and maintain key performance and risk indicators for the payor audit and enrollment data program, monitor performance against them, and propose thresholds and corrective action where results fall short.• Monitor regulatory, accreditation, and payor policy changes affecting payor audit, delegated credentialing, and provider enrollment; assess operational impact and implement required process, documentation, or system changes.• Develop training and reference materials for credentialing, billing, and practice operations teams, and represent the payor audit and enrollment data function on cross-functional projects involving payor onboarding, practice integration, and system implementations.Scope, Autonomy & Decision Authority:• Operates with substantial independence under general direction; sets own priorities and work methods and is evaluated on program outcomes rather than task completion, exercising independent judgment on matters of significance such as audit response strategy, risk classification, and remediation priority.• Recognized technical authority on payor audit, delegated credentialing, and provider enrollment data; develops and recommends policy, standards, and process changes for Credentialing leadership approval and adoption across Credentialing, Billing, and practice operations. Decisions directly affect network participation, compliance exposure, and claim revenue across all supported practice locations.• No direct reports; provides technical leadership and work direction to less-experienced credentialing and enrollment staff.Work Environment: This is a full-time, remote position supporting a multi-site, multi-state practice environment. Work is performed in a home office setting with reliable high-speed internet and a private, secure workspace appropriate for handling confidential provider, patient, and contractual information. The role collaborates virtually with Credentialing, Compliance, Billing, Revenue Cycle, and practice operations partners, and communicates directly with payors, delegation oversight teams, and the clearinghouse vendor. Standard business hours apply, with occasional extended hours to meet payor-imposed audit deadlines or delegated audit schedules. Limited travel may be required for department or organizational meetings.Physical Demands

This is a sedentary role. The position requires prolonged periods of sitting at a desk and working on a computer, extensive use of a keyboard, mouse, and monitors, and frequent communication by telephone, video conference, and email. Must be able to read, review, and analyze detailed documentation and data with accuracy, and occasionally lift or move office equipment or files weighing up to 15 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.Competencies: • Analytical & Risk Judgment – Evaluates complex audit, contractual, and enrollment data to identify risk, determine root causes, and decide on the appropriate course of action.• Written & Verbal Communication – Authors clear, persuasive formal correspondence and explains complex compliance and enrollment matters to payors, leadership, and staff.• Technical & Systems Proficiency – Applies deep working knowledge of DentalXchange, dental billing, CDT coding, and EDI/ERA processes to manage enrollment data with accuracy.• Process & Program Ownership – Designs, documents, and continuously improves audit-readiness controls, policies, and reporting from the ground up.• Influence & Mentorship – Advises senior leaders and guides less-experienced credentialing and enrollment staff without formal supervisory authority

Qualifications

High school diploma or equivalent required; bachelor's degree in healthcare administration, business, or a related field preferred.• Six or more years of progressively responsible experience in dental or medical credentialing, payor enrollment, or healthcare revenue cycle, including demonstrated ownership of a program, process, or system rather than tasklevel execution.• Direct, hands-on experience leading or materially supporting payor audits and delegated credentialing audits, including corrective action planning and closure.• Demonstrated experience interpreting payor contracts, delegation agreements, and NCQA/URAC-aligned credentialing standards and applying them to operational decisions.• Experience in a multi-site, multi-state healthcare or DSO environment strongly preferred.• CPCS, CPMSM, or comparable credentialing/compliance certification preferred.