Job Details

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:

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

Required Knowledge, Skills, and Abilities:

• Knowledge of professional practice, leadership, ethical conduct, customer client focus, proficiency with credentialing software and databases.
• Strong knowledge of healthcare regulations, privacy laws, and industry standards.
• Ability to read, interpret, comprehend, and comply with written documents or instructions furnished through various modes, including written, oral, diagram, or schedule format.
• Ability to listen, communicate, and constantly interact with a wide range of diverse individuals and personalities professionally.
• Intermediate skills in successfully operating computer equipment and general software applications, including word processing, spreadsheets, presentation software, database programs, and a general understanding and skill working with enterprise software programs.
• Ability to work effectively in a dynamic environment presenting multiple priorities.
• Excellent interpersonal, communication, and written skills; proven ability to work independently with various stakeholders.
• Good practical experience with MS Office and program management software.
• Strong organizational and leadership skills with business-oriented thinking.
• Strong analytical and problem-solving skills, with good strategic ability.
• Public speaking and presentation.
• Yaqui culture, customs, resources, and traditions, and/or a willingness to learn.

Education, Certifications, and Experience Required:

• Bachelor's degree in healthcare administration, business, or a related field; minimum of 2 years of experience in healthcare credentialing, contracting, or provider enrollment; and familiarity with credentialing software, PECOS, and payer enrollment processes; or an equivalent combination of education and experience sufficient to successfully perform the essential duties of the job such as those listed above.
• Master's degree in healthcare administration, business, or a related field.
• 3-5 years of experience in healthcare contract negotiation, payer relations, or credentialing.
• Certification in credentialing (e.g., CPCS, CPMSM) is preferred. Certification must be obtained within two (2) years of employment with PYTHSD.
• Must possess and maintain a valid Arizona Driver's License.
• Must have a current Level 1 Arizona Clearance Card or be able to obtain one within ninety (90) days of hire. Failure to maintain a current Level 1 Clearance Card will result in termination from this position.