[Hiring] Payor Audit & Enrollment Specialist @Dental Care Alliance

Role Description

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.
  • Independently evaluate each audit request to determine scope, exposure, and response strategy.
  • Analyze practice, billing, and clinical records to construct the factual record supporting each response.
  • Negotiate response timelines and extension requests with payor audit and network management contacts.
  • Analyze audit outcomes, root causes, and turnaround performance; translate findings into recommendations.
• Delegated Credentialing Oversight & Audit Readiness
  • Own the organization's delegated credentialing audit program.
  • Lead the technical execution of pre-delegation and periodic delegated audits.
  • Conduct internal file audits and mock audits against NCQA/URAC-aligned and payor-specific standards.
  • Draft and recommend corrective action plans in response to audit findings.
• Provider Enrollment & Clearinghouse Data Governance (DentalXchange)
  • Serve as system subject-matter expert and data owner for provider enrollment information within DentalXchange.
  • Define and maintain the end-to-end enrollment workflow connecting credentialing, contracting, and clearinghouse activation.
  • Design and perform recurring data integrity reviews reconciling demographic, NPI, tax ID, and enrollment data.
  • Serve as the designated system owner for the DentalXchange platform relationship.
• Billing Data Integrity & Revenue Protection
  • Define the record-keeping standards and reconciliation cadence required to support clean claims submission.
  • Reconcile payor enrollment and effective-date records against credentialing and contracting status.
  • Analyze denial and rejection trends attributable to enrollment or credentialing defects.
  • Partner with Billing and Revenue Cycle leadership to prioritize remediation for providers or locations at risk.
• Program Governance, Reporting & Continuous Improvement
  • Build and maintain the reporting package for payor audit volume, outcomes, cycle time, and enrollment data quality.
  • Recommend and maintain key performance and risk indicators for the payor audit and enrollment data program.
  • Monitor regulatory, accreditation, and payor policy changes affecting payor audit and delegated credentialing.
  • Develop training and reference materials for credentialing, billing, and practice operations teams.
• Scope, Autonomy & Decision Authority
  • Operates with substantial independence under general direction; sets own priorities and work methods.
  • Recognized technical authority on payor audit, delegated credentialing, and provider enrollment data.
  • No direct reports; provides technical leadership and work direction to less-experienced credentialing and enrollment staff.

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.
• Direct, hands-on experience leading or materially supporting payor audits and delegated credentialing audits.
• Demonstrated experience interpreting payor contracts, delegation agreements, and NCQA/URAC-aligned credentialing standards.
• Experience in a multi-site, multi-state healthcare or DSO environment strongly preferred.
• CPCS, CPMSM, or comparable credentialing/compliance certification preferred.

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.

Physical Demands

This is a sedentary role requiring prolonged periods of sitting at a desk and working on a computer. Must be able to read, review, and analyze detailed documentation and data with accuracy.

Competencies

• Analytical & Risk Judgment – Evaluates complex audit, contractual, and enrollment data to identify risk.
• Written & Verbal Communication – Authors clear, persuasive formal correspondence.
• Technical & Systems Proficiency – Applies deep working knowledge of DentalXchange, dental billing, CDT coding, and EDI/ERA processes.
• Process & Program Ownership – Designs, documents, and continuously improves audit-readiness controls, policies, and reporting.
• Influence & Mentorship – Advises senior leaders and guides less-experienced credentialing and enrollment staff.