Payer Relations and Credentialing Manager Remote

Achievement Behavior Services; Village of Malverne (NY); À distance; USD 70 000 - 105 000; Plein temps

Résumé du poste

Achievement Behavior Services is seeking a credentialing and contracts specialist to manage initial credentialing, recredentialing, and enrollment across commercial insurance, Medicaid, CHIP, and managed care plans. You will maintain provider records, monitor deadlines, and resolve issues with insurers, coordinating across states and organizational entities.

You will also oversee contracts, amendments, and fee schedules, track reimbursements, and serve as the primary contact for contracting

Qualifications

• Minimum 2 years of experience in healthcare credentialing, insurance contracting, authorization management, or revenue cycle operations.
• Experience working with ABA providers, behavioral health organizations, or pediatric healthcare services strongly preferred.
• Strong knowledge of commercial insurance, Medicaid, CHIP, and managed care enrollment and contracting processes.
• Experience with multi-state provider credentialing and insurance network expansion preferred.
• Familiarity with CAQH, NPPES, Medicaid enrollment systems, provider portals, and insurance credentialing applications.
• Knowledge of ABA CPT codes, authorization requirements, billing guidelines, and reimbursement processes.
• Experience reviewing insurance contracts, fee schedules, provider manuals, and payer policy updates.
• Excellent communication, follow-up, organizational, and problem-solving skills.

Responsabilités

• Manage initial credentialing, recredentialing, and provider enrollment across commercial insurance, Medicaid, CHIP, and managed care plans.
• Maintain accurate provider records, including CAQH, NPPES, Medicaid enrollment, licensure, payer IDs, and organizational affiliations.
• Monitor credentialing deadlines, revalidations, and changes in payer enrollment requirements.
• Investigate and resolve credentialing, enrollment, and network participation issues directly with insurance companies, including follow-up and escalation as needed.
• Coordinate credentialing across states, insurance networks, and organizational entities.
• Maintain a centralized tracker of credentialing statuses, effective dates, deadlines, and outstanding issues.
• Oversee insurance contracts, amendments, fee schedules, and participation agreements across all states and organizational entities.
• Monitor contract renewals, reimbursement changes, payer requirements, and termination provisions.
• Review contract updates, identify financial and operational impacts, and communicate concerns to leadership.
• Coordinate with leadership on contract negotiations, reimbursement issues, and network participation decisions.
• Maintain accurate contract records and track reimbursement rates by payer, state, and CPT code.
• Serve as the primary contact for insurance contracting inquiries, discrepancies, and compliance concerns.
• Support organizational growth by researching new insurance networks, contracting opportunities, and payer participation requirements across existing and prospective states.
• Coordinate applications, credentialing, and contracting with new commercial insurers and Medicaid managed care organizations.
• Research state-specific licensure, enrollment, reimbursement rates, and insurance requirements for expansion.
• Maintain a state-by-state expansion tracker of payer opportunities, applications, contracts, and effective dates.
• Collaborate with leadership, Operations, Intake, and Business Development to evaluate and implement new payer opportunities based on financial and operational feasibility.
• Collaborate with Clinical Leadership, BCBAs, Intake, Authorizations, Staffing, and Revenue Cycle Management to resolve authorization issues, delays, denials, reductions, and appeals.
• Monitor payer-specific authorization requirements, including assessments, clinical documentation, supervision, and service delivery restrictions.
• Proactively monitor changes in insurance regulations, credentialing, authorizations, reimbursement policies, CPT codes, billing, and documentation requirements.
• Communicate directly with insurance companies to investigate policy changes, clarify requirements, and confirm effective dates.
• Evaluate the operational, clinical, and financial impact of payer updates and ensure compliance with current requirements.
• Develop and distribute policy updates to Clinical Leadership, BCBAs, Intake, Authorizations, Staffing, and Revenue Cycle Management.
• Maintain a centralized tracker of insurance policy changes, effective dates, affected payers, and implementation status.
• Serve as the primary contact for investigating and resolving complex insurance issues involving credentialing, authorizations, contracting, reimbursement, and payer policies.
• Communicate directly with insurance representatives and departments to clarify requirements, resolve discrepancies, and obtain written confirmation when possible.
• Investigate recurring insurance issues, identify root causes, and recommend solutions to prevent operational disruptions and financial losses.
• Maintain detailed records of insurance communications, reference numbers, resolutions, and outstanding follow-ups.
• Collaborate with Revenue Cycle Management and billing partners to investigate and resolve credentialing, authorization, reimbursement, and claims issues.
• Identify root causes of recurring denials and coordinate corrective actions to prevent future billing disruptions.

Connaissances

Credentialing & enrollment

Multi-state credentialing

Contracting management

Payer policy monitoring

Revenue cycle support

Issue resolution

Leadership coordination

ABA provider knowledge

Communication skills

CAQH/NPPES systems

Outils

CAQH/NPPES

Medicaid enrollment systems

Description du poste

1. Provider Credentialing & Enrollment

• Manage initial credentialing, recredentialing, and provider enrollment across commercial insurance, Medicaid, CHIP, and managed care plans.

• Maintain accurate provider records, including CAQH, NPPES, Medicaid enrollment, licensure, payer IDs, and organizational affiliations.

• Monitor credentialing deadlines, revalidations, and changes in payer enrollment requirements.

• Investigate and resolve credentialing, enrollment, and network participation issues directly with insurance companies, including follow-up and escalation as needed.

• Coordinate credentialing across states, insurance networks, and organizational entities.

• Maintain a centralized tracker of credentialing statuses, effective dates, deadlines, and outstanding issues.

2. Insurance Contract Management & Oversight

• Oversee insurance contracts, amendments, fee schedules, and participation agreements across all states and organizational entities.

• Monitor contract renewals, reimbursement changes, payer requirements, and termination provisions.

• Review contract updates, identify financial and operational impacts, and communicate concerns to leadership.

• Coordinate with leadership on contract negotiations, reimbursement issues, and network participation decisions.

• Maintain accurate contract records and track reimbursement rates by payer, state, and CPT code.

• Serve as the primary contact for insurance contracting inquiries, discrepancies, and compliance concerns.

3. Business Growth & Multi-State Insurance Expansion

• Support organizational growth by researching new insurance networks, contracting opportunities, and payer participation requirements across existing and prospective states.

• Coordinate applications, credentialing, and contracting with new commercial insurers and Medicaid managed care organizations.

• Research state-specific licensure, enrollment, reimbursement rates, and insurance requirements for expansion.

• Maintain a state-by-state expansion tracker of payer opportunities, applications, contracts, and effective dates.

• Collaborate with leadership, Operations, Intake, and Business Development to evaluate and implement new payer opportunities based on financial and operational feasibility.

4. Authorization Management & Oversight

• Collaborate with Clinical Leadership, BCBAs, Intake, and Revenue Cycle Management to resolve authorization issues, delays, denials, reductions, and appeals.

• Monitor payer-specific authorization requirements, including assessments, clinical documentation, supervision, and service delivery restrictions.

5. Insurance Policy, Regulatory & CPT Code Monitoring

• Proactively monitor changes in insurance regulations, credentialing, authorizations, reimbursement policies, CPT codes, billing, and documentation requirements.

• Communicate directly with insurance companies to investigate policy changes, clarify requirements, and confirm effective dates.

• Evaluate the operational, clinical, and financial impact of payer updates and ensure compliance with current requirements.

• Develop and distribute policy updates to Clinical Leadership, BCBAs, Intake, Authorizations, Staffing, and Revenue Cycle Management.

• Maintain a centralized tracker of insurance policy changes, effective dates, affected payers, and implementation status.

6. Insurance Issue Investigation & Resolution

• Serve as the primary contact for investigating and resolving complex insurance issues involving credentialing, authorizations, contracting, reimbursement, and payer policies.

• Communicate directly with insurance representatives and departments to clarify requirements, resolve discrepancies, and obtain written confirmation when possible.

• Investigate recurring insurance issues, identify root causes, and recommend solutions to prevent operational disruptions and financial losses.

• Maintain detailed records of insurance communications, reference numbers, resolutions, and outstanding follow-ups.

7. Revenue Cycle & Insurance Claims Support

• Collaborate with Revenue Cycle Management and billing partners to investigate and resolve credentialing, authorization, reimbursement, and claims issues.

• Identify root causes of recurring denials and coordinate corrective actions to prevent future billing disruptions.

Preferred Qualifications

• Minimum 2 years of experience in healthcare credentialing, insurance contracting, authorization management, or revenue cycle operations.

• Experience working with ABA providers, behavioral health organizations, or pediatric healthcare services strongly preferred.

• Strong knowledge of commercial insurance, Medicaid, CHIP, and managed care enrollment and contracting processes.

• Experience with multi-state provider credentialing and insurance network expansion preferred.

• Familiarity with CAQH, NPPES, Medicaid enrollment systems, provider portals, and insurance credentialing applications.

• Knowledge of ABA CPT codes, authorization requirements, billing guidelines, and reimbursement processes.

• Experience reviewing insurance contracts, fee schedules, provider manuals, and payer policy updates.

• Excellent communication, follow-up, organizational, and problem-solving skills.