Job Description

The Utilization/Credentialing Specialist is responsible for supporting Comprehend's billing and clinical operations by ensuring timely submission and tracking of authorizations, managing provider credentialing, and maintaining compliance with payer and regulatory requirements. This position also provides general clerical support at the clinical level as needed.

Role and Responsibilities

Essential Duties & Responsibilities

Provider Credentialing & Enrollment

Lead all initial and re-credentialing activities for Comprehend providers. Maintain up-to-date provider files, including licensure, certifications, and required verifications. Manage payer enrollment processes across Medicaid, Medicare, MCOs, and commercial insurers. Update and maintain provider data in NPPES, CCBHC, PECOS, and payer portals. Coordinate enrollment activities with HR and Billing to ensure providers are active with payers without delays. Track expiring documents and proactively initiate re-credentialing steps.

Utilization Management

Serve as a primary support contact for authorization and utilization processes. Request, track, and renew authorizations for clinical services. Monitor authorization status to prevent service interruptions or claim denials. Communicate regularly with clinical teams to ensure appropriate documentation supports payer requirements. Partner with Billing to resolve utilization-related denials and improve workflows. Maintain utilization logs and provide updates to leadership regarding trends, expirations, and risk areas.

Intake Coordination (Added Responsibilities -- Oversight & Coordination Role)

Provide

oversight and coordination

of the entire intake process to ensure all clerical staff complete required steps accurately and in compliance with CCBHC, State, and organizational standards. Monitor and ensure clerical staff properly gather and verify demographic, insurance, and eligibility information prior to scheduling. Oversee coordination with clinical teams to ensure timely and appropriate appointment scheduling based on service needs, program availability, and client acuity. Ensure intake workflows meet

CCBHC access requirements

, including same-day and next-day appointment expectations when applicable. Review, audit, and ensure accurate documentation of intake data in the EHR; provide guidance and correction as needed. Serve as the point of escalation for intake-related issues, ensuring consistent communication, quality control, and adherence to established procedures

General Responsibilities

Uphold confidentiality and HIPAA standards across all credentialing, intake, and utilization functions. Assist with audits, chart reviews, payer requests, and compliance monitoring related to credentialing and utilization. Participate in workflow development, process improvements, and cross-departmental coordination (Clinical, Billing, HR, and Leadership). Support the Billing Coordinator, Senior Accounting & Operations Specialist and CFO with reporting, tracking, and documentation needs. Other Duties as needed

Qualifications and Education Requirements

High school diploma or GED required, associate degree in healthcare administration or related field preferred. Minimum of one (1) year of experience in billing, utilization review, or credentialing preferred. Working knowledge of Medicaid/Medicare and commercial insurance requirements. Experience with electronic health record systems (CareLogic preferred). Excellent organizational and time management skills. Ability to maintain confidentiality and adhere to HIPAA standards.

Physical Requirements:

Ability to sit, stand, and use a computer for extended periods. Must be able to travel between clinic sites as needed.

Special Requirements:

Valid driver's license and dependable transportation

Travel Requirements:

* This position will require occasional travel to Comprehend's outpatient offices located in Fleming, Lewis, and Mason counties for Clerical Support.