Credentialling & ProviderEnrollmentSpecialist

Prestige-Healthcare-Resources-Inc; Washington (District of Columbia); Presencial; USD 32 000 - 34 000; Tempo integral

Resumo da oferta

Prestige Healthcare Resources, Inc. in Washington, DC seeks a Credentialing & Provider Enrollment Specialist to own end-to-end credentialing and enrollment for clinicians and the organization, ensuring records are accurate, licenses current, and enrollments move from submission to approval.

The role collaborates with Billing, Compliance, Clinical Operations, and the AI transformation team to improve provider data quality and revenue-cycle workflows, with emphasis on accuracy and regulatory

Qualificações

• At least 3 years of credentialing or provider enrollment experience, including Medicaid/Medicaid MCOs.
• Hands-on experience with CAQH ProView, NPPES, PECOS, and payer enrollment portals.
• Working knowledge of DC/Maryland licensure requirements for behavioral health professionals.

Responsabilidades

• Verify licenses, certifications, education, and work history before first assignment.
• Conduct exclusion and sanction screenings at hire and monthly (OIG LEIE, SAM.gov, state lists, NPDB as required).
• Maintain audit-ready credentialing files for clinicians and contractors.
• Identify missing or inconsistent documentation and coordinate timely resolution.
• Manage initial enrollment, recredentialing, revalidation, and updates across Medicaid programs, PECOS, and commercial payers.
• Maintain CAQH ProView profiles and required attestations.
• Ensure alignment of NPIs, taxonomies, and practice locations with payer records.
• Track applications from submission through approval and follow-up until resolution.

Conhecimentos

Credentialing

Provider enrollment

Medicaid enrollment

NPPES

CAQH ProView

Payer portals

Data integrity

HIPAA compliance

Detail-oriented

Formação académica

Bachelor's degree in healthcare administration or related field

Ferramentas

CAQH ProView

NPPES

PECOS

Credible

Payer portals

EHR system

Descrição da oferta de emprego

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Full Time Washington, DC, US

2 days ago Requisition ID: 1256

Salary Range: $23.00 To $25.00 Hourly

CREDENTIALING & PROVIDER ENROLLMENT SPECIALIST

Keep Providers Ready. Protect Revenue. Build Smarter Healthcare Operations.

PRESTIGE HEALTHCARE RESOURCES, INC. (PHRI)

Location: Washington, DC | On-site

Employment: Full-time, exempt

Compensation: $23 to $25 per hour

Your Work Matters More Than You Think

Behind every successful Consumer visit is a healthcare professional who is properly licensed, credentialed, and approved to provide services. At Prestige Healthcare Resources, Inc. (PHRI), we're looking for a detail-driven, proactive Credentialing & Provider Enrollment Specialist who understands that credentialing is more than paperwork—it's a critical part of patient access, regulatory compliance, and revenue protection.

You'll take ownership of the end-to-end credentialing and enrollment lifecycle for our clinicians and organization, ensuring provider records are accurate, licenses and certifications remain current, and payer enrollments move from submission to approval.

PHRI is also advancing AI-enabled revenue-cycle operations. Your expertise will help establish the reliable provider data and workflows that make smarter, more efficient healthcare operations possible.

If you're someone who anticipates problems before they happen, follows through until the job is done, and takes pride in getting the details right, we'd love to meet you.

Why This Opportunity Is Worth Exploring

• Own work that makes a real difference. Help ensure clinicians are properly credentialed and eligible to serve patients and bill for services, while preventing avoidable enrollment-related disruptions.
• Be trusted to take ownership. Manage work from application submission through payer approval, proactively track renewals, resolve discrepancies, and elevate risks before they become problems.
• Work at the intersection of healthcare and technology. Collaborate with Billing, Compliance, Clinical Operations, and the AI transformation team to improve provider data quality and support more effective workflows.
• Build valuable, transferable expertise. Strengthen experience in Medicaid and MCO enrollment, regulatory compliance, revenue-cycle operations, data integrity, and process improvement. Certification development may be an option for qualified candidates.
• Know what success looks like. Work toward clear priorities and measurable outcomes, with an initial 90-day focus on accurate records, closing critical gaps, and reliable credentialing processes.

What You'll Own

• Verify professional licenses, certifications, education, and work history before a clinician's first assignment.
• Conduct and document required exclusion and sanction screenings at hire and monthly, including OIG LEIE, SAM.gov, applicable state Medicaid exclusion lists, and NPDB checks where required.
• Maintain complete, accurate, confidential, and audit-ready credentialing files for clinicians and contractors.
• Identify missing, expired, or inconsistent documentation and coordinate timely resolution.
• Manage initial enrollment, recredentialing, revalidation, and demographic updates across DC Medicaid, Maryland Medicaid, Medicaid managed care organizations (MCOs), Medicare through PECOS, and commercial payers.
• Maintain CAQH ProView profiles, supporting documents, and required attestations within authorized access.
• Ensure individual and organizational National Provider Identifiers (NPIs), taxonomies, and practice locations in NPPES align with payer records.
• Track applications from submission through approval and effective date, following up consistently until each case is resolved.

3. Organizational & Program Credentialing

• Support Department of Behavioral Health (DBH) certification, organizational enrollment, and site or service additions.
• Coordinate updates involving provider names, locations, supervision arrangements, and service lines across all affected systems.
• Maintain supporting documentation and ensure applicable requirements are addressed as the organization evolves.

4. Data Integrity, Tracking & Contract Management

• Own the credentialing and enrollment tracker as PHRI's central source of truth for provider status, licenses, certifications, enrollment progress, and contract dates.
• Implement and maintain 90-, 60-, and 30-day renewal alerts, escalating potential lapses promptly.
• Maintain the central contract database, including effective dates, expiration dates, renewal dates, and supporting documents.
• Reconcile provider information across Credible, CAQH, NPPES, and payer portals at least monthly.
• Identify opportunities to simplify tracking, strengthen controls, and improve workflow efficiency.

5. Revenue-Cycle Partnership & Process Improvement

• Communicate each clinician's payer-specific billable status to Intake, Scheduling, and the Authorization Team before assignment.
• Partner with Billing to investigate and resolve credentialing-related denials, including enrollment gaps and NPI or taxonomy mismatches.
• Provide reliable provider data and business rules to the AI transformation team.
• Help validate AI-enabled workflows that use credentialing information and flag inaccurate or inconsistent outputs.
• Document repeatable processes and contribute to stronger standard operating procedures.

6. Communication, Reporting & Accountability

• Prepare monthly reports covering provider credentialing status, pending enrollments, upcoming expirations, risks, and barriers.
• Guide clinicians through credentialing requirements and communicate outstanding documentation clearly.
• Keep hiring managers and relevant stakeholders informed about enrollment progress and onboarding timelines.
• Escalate compliance and revenue risks early, with recommended next steps.

What We're Looking For

Required Qualifications

• At least 3 years of credentialing or provider enrollment experience, including at least 2 years working with Medicaid and Medicaid MCOs.
• Hands-on experience with CAQH ProView, NPPES, PECOS, and payer enrollment portals.
• Working knowledge of Washington, DC, and Maryland licensure requirements for behavioral health professionals, including applicable social workers, counselors, marriage and family therapists, psychologists, psychiatric nurse practitioners, and physicians.
• Strong spreadsheet, database, and record-management skills, with experience using an EHR or credentialing system.
• Demonstrated ability to manage multiple applications, deadlines, and renewal cycles without losing track of details.
• Ability to handle confidential information responsibly and comply with applicable HIPAA and 42 CFR Part 2 requirements.

Preferred Qualifications

• Bachelor's degree in healthcare administration, business, or a related field; equivalent relevant experience will be considered.
• CPCS (Certified Provider Credentialing Specialist) or CPMSM certification through NAMSS, or willingness to pursue CPCS within 18 months.
• Experience in behavioral health, community mental health, DBH certification, or DC Medicaid enrollment.
• Experience with Credible, credentialing platforms, workflow automation, or process improvement.

ENCOURAGING QUALIFIED APPLICANTS

Don't meet every preferred qualification? If you meet the core requirements and bring strong, relevant experience, we encourage you to apply.

Your First 90 Days

Days 1–30: Understand & Assess
Learn PHRI's systems and workflows, inventory clinician records and contracts, and establish a baseline tracker covering all clinicians and contracts.

Days 31–60: Resolve & Stabilize
Prioritize high-risk gaps, address expiring licenses and enrollment issues, submit pending applications, and implement consistent renewal alerts and data reconciliation.

Days 61–90: Standardize & Improve
Document credentialing procedures, launch monthly reporting, identify denial root causes with Billing, and provide reliable provider data requirements to the AI transformation team.

By day 90, the goal is a complete view of active clinician credentialing, documented billable status by payer, and a clear action plan for outstanding risks.

How You Work Matters, Too

• Takes ownership: Follows applications through to approval rather than stopping at submission.
• Thinks ahead: Identifies upcoming expirations or enrollment gaps before they disrupt operations.
• Values accuracy: Understands that one incorrect NPI, taxonomy, or location can create downstream problems.
• Understands the business: Connects credentialing accuracy to authorizations, claims, cash flow, and patient access.
• Communicates with professionalism: Follows up firmly and respectfully with busy clinicians and internal stakeholders.
• Builds better systems: Documents processes, maintains reliable trackers, and looks for practical workflow improvements.
• Acts with integrity: Protects confidential information and never attests, certifies, or signs beyond their authority.

Work Arrangement

• Location: PHRI's Washington, DC office.
• Schedule: Full-time, on-site.
• Compensation: $23 to $25 per hour
• Working conditions: Periodic workload peaks during revalidation and audit cycles, with occasional coordination outside normal business hours when necessary to meet payer or regulatory deadlines.

Ready to Make an Impact?

If you're a credentialing professional who can keep complex enrollment processes organized, protect compliance, and help healthcare operations run more effectively, we want to hear from you. Bring your expertise, your attention to detail, and your commitment to getting things right.