Position Summary
The Credentialing & Payor Contract Manager oversees all aspects of provider credentialing, payer enrollment, and network contract analysis across the organization’s entities and Tax Identification Numbers (TINs). This role ensures timely and compliant onboarding of providers with insurance carriers, accurate contract setup, and optimized payer participation that supports clean claims and maximized reimbursement. The position serves as both a departmental leader—managing and supervising the Credentialing Lead and team members within the credentialing department—and a strategic analyst responsible for contract oversight, financial impact analysis, and continuous process improvement across all payer relationships.
Key Responsibilities
1. Leadership & Department Oversight
Supervise and mentor the Credentialing Team Lead and Credentialing Specialists.
Set priorities, assign workload, and monitor key credentialing and enrollment milestones.
Establish and maintain department-wide performance standards, turnaround times, and service-level expectations.
Conduct weekly status meetings to review progress, escalate payer issues, and track outstanding applications.
Lead training initiatives to improve documentation accuracy, payor communication, and compliance consistency.
Support staffing evaluations, onboarding, and performance assessments within the credentialing department.
2. Credentialing Operations & Process Optimization
Oversee the complete provider lifecycle: initial credentialing, recredentialing, demographic updates, and payer terminations.
Validate the accuracy of CAQH profiles, NPI registration, malpractice certificates, and state licensure documentation.
Ensure all submissions and updates are made promptly to payor portals and delegated networks.
Implement process improvements to reduce credentialing delays and prevent enrollment-related claim denials.
Develop and maintain a Credentialing SOP Manual and Key Performance Indicator (KPI) dashboard.
3. Payor Contract Analysis & Management
Review and analyze all payer contracts, amendments, and reimbursement structures to ensure financial alignment with business objectives.
Evaluate contract participation options (direct, leased, delegated, or indirect) and provide recommendations to leadership.
Maintain and update master databases of all payer fee schedules, effective dates, and renewal terms.
Compare contracted reimbursement rates with posted claim data to identify underpayments or rate discrepancies.
Prepare financial impact summaries for new payor participation or contract renegotiation opportunities.
4. Network Participation & Relationship Management
Monitor and document each provider’s participation status across networks, plans, and service locations.
Maintain an active provider roster, detailing plan affiliations, effective dates, and reimbursement categories.
Serve as primary liaison with payer representatives, credentialing contacts, and network administrators.
Escalate unresolved credentialing or contracting issues to appropriate payer or internal leadership channels.
5. Reporting, Metrics, & Compliance
Track department’s credentialing turnaround, recredentialing renewals, and enrollment cycle times.
Audit payer rosters and credentialing data monthly to ensure alignment between internal systems and payer records.
Ensure compliance with payer, HIPAA, NCQA, and state/federal regulations.
Prepare executive-level reports on network status, payer trends, and credentialing performance metrics.
Maintain an audit-ready documentation repository for external payer or regulatory reviews.
Qualifications
Education:
- Bachelor’s degree in healthcare administration, Business, or related field required.
- NAMSS Certification (CPCS or CPMSM) a plus.
Experience:
- 5+ years of progressive experience in healthcare credentialing and payer contracting.
- Minimum 2 years in a leadership or supervisory role overseeing credentialing or provider enrollment staff.
- Strong understanding of provider network participation models (direct, leased, delegated).
- Experience analyzing fee schedules, payer reimbursements, and network economics.
- Familiarity with practice management systems (Dentrix, Open Dental, or similar) and credentialing platforms (CAQH, Availity, OneHealthPort).
Skills & Competencies:
- Advanced Excel and data analysis proficiency for contract comparison and trend reporting.
- Strong leadership, mentoring, and communication skills.
- Detail-oriented with high accuracy in documentation and recordkeeping.
- Ability to interpret contractual language and financial terms.
- Organized, deadline-driven, and capable of balancing multiple priorities.
Job Type: Full-time
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Retirement plan
- Vision insurance
Work Location: In person
