Credentialing and Payer Contract Specialist

Job Description

Job Description

Description:

Job Title: Credentialing and Payer Contract Specialist

Location: Richmond Hill, GA (Remote-Hybrid)

Employment Type : Full-time

Reports To: Director of Revenue Cycle Department: Revenue Cycle

Job Summary: The Credentialing and Payer Contract Specialist is responsible for ensuring that healthcare providers are properly credentialed, licensed, and enrolled with the necessary organizations and insurance companies. This role requires meticulous attention to detail, strong organizational skills, and the ability to manage multiple tasks simultaneously. The Credentialing and Payer Contract Specialist will work closely with healthcare providers, insurance companies, and other stakeholders to maintain compliance with all relevant regulations and standards.

Key Responsibilities:

Provider Credentialing:

o Manage the initial credentialing and re-credentialing process for all healthcare providers.

o Ensure all documentation and provider information, including licenses, certifications, and insurance coverages, remain current and compliant with state and federal regulations.

o Timely, prepare and submit credentialing and re-credentialing applications to various insurance companies, hospitals, and other healthcare organizations.

Enrollment & Licensing:

o Handle the enrollment of providers with insurance companies, Medicare/Medicaid, and other third-party payers.

o Coordinate and manage the licensing and certification renewal process for healthcare providers.

o Maintain accurate and up-to-date records of all credentials, licenses, and certifications.

Compliance & Audits:

o Ensure compliance with all relevant credentialing and licensing regulations.

o Prepare for and participate in audits related to provider credentials.

o Stay updated on changes in credentialing requirements and regulations.

o Ensure credentialing and enrollment processes comply with applicable regulatory and accreditation standards including, but not limited to: CMS, Medicare, Medicaid, NCQA, and applicable state licensing boards.

o Maintain strict confidentiality of sensitive provider and organizational information in accordance with HIPAA and applicable organizational privacy policies.

Communication & Support:

o Serve as a point of contact for providers and staff regarding credentialing and enrollment inquiries.

o Communicate with insurance companies, hospitals, and other entities to resolve any issues related to provider credentialing.

o Provide regular updates to management on the status of credentialing activities.

Documentation & Reporting:

o Maintain organized and accurate credentialing files and electronic databases.

o Generate reports on credentialing status and upcoming renewals.

o Ensure timely follow-up on pending credentialing and re-credentialing applications.

o Maintain up-to-date digital file of all payor plans by provider and by location.

Payer and Managed Care Contracts

o Manage and maintain payer and managed care contracts, including tracking renewals, amendments, and terminations.

o Review contract terms, reimbursement schedules, and requirements to ensure accuracy and organizational compliance.

o Coordinate with payers and internal departments to resolve contract-related issues and support negotiations.

o Maintain organized and accurate contract documentation and key dates within the contract management, credentialing system, or databases.

Additional Duties:

o May support Revenue Cycle operations through special projects or additional duties as needed to support departmental and organizational objectives.

Education:

o Associate’s or Bachelor’s degree in healthcare administration, business administration, or a related field (preferred).

o Relevant certification in credentialing (e.g., CPCS, CPMSM) is a plus.

Experience:

o Minimum of 2-3 years of experience in credentialing within a healthcare setting.

o Experience with credentialing software and databases is preferred.

o Experience with Medicare PECOS enrollment and CAQH management is preferred.

Skills:

o Strong attention to detail and organizational skills.

o Excellent written and verbal communication skills.

o Works within established policies and procedures while exercising independent judgment to resolve issues.

o Ability to manage multiple tasks and deadlines simultaneously.

o Proficiency in Microsoft Office Suite (Word, Excel, Outlook).