Credentialing & Contracting Manager

Job Summary:

The Credentialing and Contracting Manager oversees the strategic and operational execution of provider enrollment, network participation, and insurance contract negotiations. This leadership role ensures that all medical or behavioral health professionals within the organization are accurately credentialed, enrolled with payers, and aligned with optimal reimbursement terms to drive revenue cycle success and maintain regulatory compliance.

Key Responsibilities:

Provider Credentialing & Enrollment
Application Management: Oversee and direct the full lifecycle Of initial
credentialing, re«edentialing, and provider roster management across commercial,
Medicare, and Medicaid networks.
Platform Governance: Maintain absolute accuracy in central identity databases
including CAQH Proview, PECOS, NPPES (NP' registration), and specific state
Medicaid portals.
Expiry Tracking: Design and manage rigorous monitoring systems for the timely
renewal of medical licenses, malpractice insurance policies, DEA certificates, and
payer revalidation timdines to mitigate billing conWiance risks.
2. Payer Contracting & Rate Negotiation
Contract Management: Review, redine, and manage managed care organization
(MCO) contracts, single-case agreements, and fee schedule amendments.
Financial Analysis: Partner with corporate leadership to analyze reimbursement
rate Structures, evaluating financial impacts against local market benchmarks
payer Rdations: Build and sustain strategic relationships with payer network
managers to expedite enrollment workflows and resolve structural claims issues.
3. Compliance & Cross-Functional Operations
Regulatory Standards: Guarantee Organizational readiness and compliance wid.
NCQA, URAC, CMS, and local state department Of health requirements.
Revenue Alignment: Collaborate closely with medical billing, coding, and
finance teams to audit and resolve enrollment-related claims denials or holds.
Process Optimization: Standardize workflow operations by building KPI tracking and writing standard operating procedures (Sops).

Qualifications:
Education: Bachelors degree in Healthcare Administration, Business Management,
or a strictly related field required.
Experience: Minimum of æ5 years of direct healthcare credentialing and insurance
contracting experience, demonstrating progressive leadership Or management
oversight.
Certifications: Certified provider Credentialing Specialist (CPCS) Or Certified
Professional Medical Services Management (CPMSM) highly preferred.
Skills: Advanced data parsing skills, profound familiarity with managed Care
terminology, and strong negotiation capabilities