Credentialling & ProviderEnrollmentSpecialist

PRESTIGE HEALTHCARE RESOURCES INC • Washington, DC

25d • $23 - $25 • Onsite

About The Position

Prestige Healthcare Resources, Inc. (PHRI) is hiring a full-time, exempt Credentialing & Provider Enrollment Specialist for its Washington, DC office. This on-site role owns the end-to-end credentialing and enrollment lifecycle for clinicians and the organization. The specialist ensures provider records are accurate, licenses and certifications remain current, and payer enrollments progress from submission through approval, supporting patient access, regulatory compliance, and revenue protection.

The role covers primary-source verification; exclusion and sanction screenings; clinician and organizational enrollment with Medicaid programs, managed care organizations, Medicare, and commercial payers; DBH certification support; provider data and contract tracking; renewal alerts; data reconciliation; and communication of payer-specific billable status. The specialist partners with Billing, Compliance, Clinical Operations, Intake, Scheduling, the Authorization Team, and PHRI’s AI transformation team to resolve enrollment issues, improve workflows, and validate provider data used in AI-enabled processes. The position also prepares monthly status and risk reports, guides clinicians through requirements, documents repeatable procedures, and escalates compliance or revenue risks.

The schedule is full-time and on-site. Compensation is $23 to $25 per hour. Workload may peak during revalidation and audit cycles, and occasional coordination outside normal business hours may be necessary to meet payer or regulatory deadlines.

Requirements

• 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.
• Ability to manage multiple applications, deadlines, and renewal cycles while maintaining attention to detail.
• Ability to handle confidential information responsibly and comply with applicable HIPAA and 42 CFR Part 2 requirements.

Nice To Haves

• 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.
• Certification development may be an option for qualified candidates.

Responsibilities

• Verify clinicians’ professional licenses, certifications, education, and work history before their 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 and resolve missing, expired, or inconsistent documentation.
• Manage initial enrollment, recredentialing, revalidation, and demographic updates across DC Medicaid, Maryland Medicaid, Medicaid MCOs, Medicare through PECOS, and commercial payers.
• Maintain CAQH ProView profiles, supporting documents, and required attestations within authorized access.
• Ensure individual and organizational NPIs, taxonomies, and practice locations in NPPES align with payer records.
• Track applications from submission through approval and effective date, following up until each case is resolved.
• Support DBH certification, organizational enrollment, and site or service additions.
• Coordinate changes to provider names, locations, supervision arrangements, and service lines across affected systems, maintaining supporting documentation and addressing applicable requirements.
• Own and maintain the credentialing and enrollment tracker as the central source of truth for provider status, licenses, certifications, enrollment progress, and contract dates.
• Implement and maintain 90-, 60-, and 30-day renewal alerts and promptly escalate potential lapses.
• Maintain the central contract database, including effective, expiration, and 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.
• Communicate clinicians’ 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 and help validate AI-enabled workflows for inaccurate or inconsistent outputs.
• Document repeatable processes and contribute to stronger standard operating procedures.
• Prepare monthly reports on credentialing status, pending enrollments, upcoming expirations, risks, and barriers.
• Guide clinicians through credentialing requirements and clearly communicate outstanding documentation.
• Keep hiring managers and relevant stakeholders informed about enrollment progress and onboarding timelines.
• Escalate compliance and revenue risks early and recommend next steps.

Benefits

• 401(k)
• Dental insurance
• Health insurance
• Vision insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed