Contracting & Credentialing Specialist

Contracting & Credentialing Specialist

This dual-role position is responsible for negotiating and managing payer contracts while overseeing the credentialing and re-credentialing of healthcare providers. The Contracting & Credentialing Specialist ensures that payer agreements align with the organization's financial and operational goals and that all providers meet regulatory and accreditation requirements.

Principle Duties and Responsibilities :

• Negotiate and manage contracts with commercial insurers, Medicare, Medicaid, and other third-party payers.
• Analyze reimbursement rates and contract terms to ensure financial sustainability.
• Monitor contract performance, including payment accuracy and payer compliance.
• Collaborate with internal stakeholders, including finance, legal, and revenue cycle teams, to optimize contract terms.
• Maintain a database of contracts, expiration dates, and amendments, ensuring timely renewals and updates.
• Maintain strong relationships with payer representatives and resolve contract-related issues.
• Process initial credentialing and re-credentialing applications for providers, ensuring compliance with regulatory requirements.
• Collect, verify, and maintain provider credentials, including licensure, certifications, education, and work history.
• Monitor upcoming expirations for licenses, certifications, and payer enrollments to ensure uninterrupted provider participation.
• Conduct background checks, malpractice history reviews, and sanction screenings.
• Coordinate with national and state credentialing bodies, such as CMS, NCQA, and others to ensure timely approval.
• Maintain provider data in credentialing software and update records as needed.
• Submit and follow up on provider enrollment applications with payers to ensure timely approvals.
• Ensure compliance with healthcare regulations, including, but not limited to, HIPAA, NCQA, and CMS guidelines.
• Stay up to date with changes in credentialing and contracting regulations to ensure the organization remains compliant.
• Assist in audits and reporting related to provider credentialing and contracting.
• Serve as the main point of contact for providers regarding credentialing and contracting inquiries.
• Work collaboratively with internal departments, including HR, billing, and compliance teams, to ensure provider credentialing is completed efficiently.
• Provide education and support to providers regarding credentialing requirements and processes.

Required Knowledge, Skills, and Abilities :

Education, Certifications, and Experience Required :