Credentialing & Provider Enrollment Specialist

Odyssey House•Salt Lake City, UT

2d•Onsite

About The Position

Odyssey House of Utah is seeking a Full-Time Credentialing Provider Enrollment Specialist! The Credentialing & Provider Enrollment Specialist is responsible for ensuring Odyssey House facilities, programs, and healthcare providers are accurately and timely credentialed, enrolled, and maintained with Medicaid, Medicaid managed care organizations, commercial insurance plans, Medicare, and other applicable funders. This position owns two interconnected credentialing functions: facility/site credentialing and individual provider credentialing and enrollment. The Specialist maintains accurate records of all credentialed Odyssey House locations and coordinates payer enrollment when locations open, change, or close. The position also manages credentialing and enrollment for new and existing behavioral health and medical providers, ensuring required documentation is collected, verified, submitted, tracked, and maintained. Working closely with Human Resources, Revenue Cycle, program leadership, and clinical and medical staff, the Specialist helps ensure providers are credentialed as quickly as possible following hire so services can be billed appropriately and prevents avoidable interruptions in reimbursement related to credentialing or enrollment.

Requirements

High school diploma or equivalent.
Two or more years of healthcare credentialing, provider enrollment, payer enrollment, medical staff services, revenue cycle, or closely related experience.
Demonstrated ability to manage a high volume of detailed, deadline-driven information accurately.
Strong organizational, follow-up, documentation, and problem-solving skills.
Ability to communicate professionally and persistently with providers, internal departments, insurance companies, government agencies, and other external partners.
Proficiency with Microsoft Office, Monday.com, or Google Workspace and ability to effectively use databases, spreadsheets, payer portals, and electronic tracking systems.
Ability to independently prioritize multiple credentialing applications, deadlines, renewals, and follow-up activities.

Nice To Haves

Experience with behavioral health, substance use disorder treatment, community mental health, integrated healthcare, or nonprofit healthcare organizations.
Experience with Utah Medicaid and Medicaid managed care/accountable care organizations.
Experience using Utah Medicaid PRISM, CAQH ProView, NPPES, Medicare, PECOS, and commercial payer credentialing portals.
Familiarity with Utah behavioral health and medical professional licenses and credentials, including CMHC, ACMHC, LCSW, CSW, SUDC, APRN, MD, and DO credentials.
Associate's or Bachelor's degree in healthcare administration, business, finance, accounting, or a related field.
Certified Provider Credentialing Specialist (CPCS) or similar credentialing certification.

Responsibilities

Maintain a comprehensive and current record of all Odyssey House facilities, service locations, programs, and their credentialing or enrollment status with applicable payers and funders.
Coordinate credentialing and enrollment of new facilities and service locations with Utah Medicaid, Medicaid managed care organizations/accountable care organizations, commercial insurance plans, Medicare, and other applicable funders.
Identify and collect required documentation for new site enrollment, including licenses, certifications, ownership information, addresses, service information, tax documentation, and other payer-required materials.
Coordinate credentialing updates when a location changes its name, address, services, licensure, ownership information, or other information relevant to payer enrollment.
Manage payer notifications and enrollment changes associated with facility closures, relocations, or discontinued services.
Track submissions, effective dates, approvals, payer IDs, service locations, revalidations, and other credentialing information to maintain an accurate source of truth for all Odyssey House locations.
Routinely reconcile internal facility records against payer enrollment records and correct discrepancies before they affect billing.
Coordinate with organizational leadership when new programs or locations are planned to identify credentialing requirements and timelines before services begin.
Manage credentialing and payer enrollment for newly hired and existing behavioral health and medical providers, including physicians, advanced practice providers, licensed and pre-licensed mental health professionals, substance use disorder counselors, and other credentialed staff as applicable.
Initiate the credentialing process promptly upon notification of a new hire to minimize delays between employment, service provision, and billable status.
Determine credentialing and enrollment requirements based on provider type, licensure, assigned program/location, services provided, and applicable payer requirements.
Collect, review, and organize required credentialing documentation, applications, attestations, licenses, certifications, insurance information, education and training documentation, and other payer-required materials.
Complete and submit provider applications and enrollment transactions through Utah Medicaid PRISM, CAQH ProView, NPPES, Medicare PECOS, payer portals, and other required credentialing systems.
Complete primary source verification and validate applicable professional licenses, certifications, NPI information, DEA registrations, controlled substance licenses, and other credentials as required.
Track each provider from initial submission through approval and effective date, conducting timely follow-up with payers when applications are pending or additional information is required.
Ensure providers are appropriately linked to Odyssey House entities, facilities, programs, groups, and billing arrangements as required by each payer.
Maintain accurate documentation of provider enrollment status and effective dates by payer and service location.
Maintain current payer rosters reflecting active providers, locations, and applicable program assignments.
Submit timely additions, removals, location changes, demographic changes, and other roster updates to applicable payers.
Coordinate credentialing changes when employees transfer between programs or service locations.
Promptly complete payer disenrollment and roster removal processes when credentialed employees separate from Odyssey House or are no longer providing services under a particular payer or location.
Monitor credential expiration and recredentialing requirements, including professional licenses, DEA registrations, controlled substance licenses, malpractice coverage, CAQH attestations, payer revalidations, and other required credentials.
Provide advance notification to providers, supervisors, Human Resources, and other responsible parties regarding upcoming credentialing requirements or expirations.
Escalate unresolved or overdue credentialing requirements before they result in an interruption in authorization to provide or bill for services.
Maintain organized, complete, accurate, and audit-ready electronic credentialing records.
Maintain a centralized credentialing tracker or database that documents provider and facility enrollment by payer, submission and effective dates, outstanding requirements, recredentialing dates, and termination dates.
Maintain provider information within CAQH ProView, NPPES, Utah Medicaid PRISM, Medicare PECOS, and applicable payer systems.
Complete required exclusion and sanction screenings and maintain documentation in accordance with organizational, payer, and regulatory requirements.
Maintain credentialing records consistent with applicable Utah Medicaid, payer, federal, accreditation, and organizational requirements.
Monitor payer communications and credentialing requirements and update internal processes when requirements change.
Support credentialing documentation requests associated with payer audits, regulatory reviews, and accreditation surveys.
Partner closely with Human Resources to establish a consistent handoff from accepted offer/new hire through credentialing completion and active payer enrollment.
Communicate credentialing requirements to newly hired providers and follow up on outstanding documentation.
Provide Revenue Cycle and operational leadership with accurate information regarding whether and when providers and locations are approved to bill particular payers.
Identify credentialing or enrollment issues that may affect claims and work with Revenue Cycle staff and payer representatives to resolve them.
Provide regular credentialing status reports identifying new-provider progress, pending payer applications, upcoming expirations, site changes, roster discrepancies, and issues requiring escalation.
Participate in development and improvement of credentialing workflows, tracking systems, policies, and internal controls.