Payer Relations and Credentialing Manager Remote

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.

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