Credentialing & Payer Contracting Specialist

We are seeking an experienced, highly organized Credentialing & Payer Contracting Specialist to join our growing behavioral health practice. This position will be responsible for provider credentialing, payer enrollment, recredentialing, commercial and government payer contracting, contract maintenance, and provider roster management.

The ideal candidate has hands-on experience working directly with commercial insurance carriers, Medicare, Medicaid, and other government programs and understands the credentialing and contracting process from initial application through final approval, effective date, and participation confirmation.

Key Responsibilities

Provider Credentialing & Recredentialing
• Manage the complete credentialing and recredentialing process for physicians, advanced practice providers, therapists, and other eligible clinicians.
• Prepare, submit, and track initial credentialing and recredentialing applications.
• Maintain accurate and current CAQH profiles and supporting documentation.
• Verify and maintain provider licenses, DEA registrations, malpractice insurance, board certifications, education, training, and other required credentials.
• Conduct primary source verification and respond to payer requests for additional documentation.
• Monitor credentialing and recredentialing deadlines to prevent lapses in participation.
• Maintain organized electronic credentialing files and provider records.
• Track applications from submission through approval and confirm provider effective dates.
• Follow up consistently with payers to prevent unnecessary credentialing delays.

Commercial Payer Contracting
• Manage contracting and enrollment activities with commercial insurance carriers and behavioral health networks.
• Prepare and submit applications for new payer contracts and network participation.
• Communicate directly with payer contracting representatives regarding applications, contract status, and participation requirements.
• Review proposed payer agreements, fee schedules, reimbursement terms, amendments, and participation requirements.
• Assist management with evaluating reimbursement rates and contract terms.
• Coordinate contract negotiations and requests for improved reimbursement rates when directed by management.
• Maintain copies of executed agreements, amendments, fee schedules, and related payer correspondence.
• Track contract renewal dates, termination provisions, notice requirements, and amendments.
• Confirm that contracted rates and effective dates are correctly implemented by payers.

Government Payer Enrollment & Contracting
• Manage provider and group enrollment with Medicare, Medicaid, and other applicable government programs.
• Complete and maintain Medicare enrollment through PECOS and other required government enrollment systems.
• Prepare initial enrollments, reassignments, changes of information, revalidations, and other Medicare submissions.
• Complete state Medicaid enrollment and revalidation requirements as applicable.
• Maintain organizational and individual provider enrollment information, including NPI, TIN, PTAN, taxonomy codes, service locations, and reassignment relationships.
• Monitor Medicare and Medicaid revalidation deadlines and regulatory enrollment requirements.
• Respond to development requests and requests for additional information from government payers.
• Track applications through approval and confirm enrollment and effective dates.
• Maintain documentation supporting government payer participation and compliance.

Provider Enrollment & Rosters
• Add newly hired providers to applicable commercial and government payer contracts.
• Submit provider additions, terminations, demographic changes, and location updates.
• Maintain accurate provider rosters across all contracted health plans.
• Complete payer roster reconciliations and respond to roster verification requests.
• Ensure provider demographic information is consistent across CAQH, NPPES, PECOS, payer systems, and internal records.
• Monitor provider directory information and coordinate corrections when discrepancies are identified.
• Track provider participation by payer, state, location, and effective date.

Contract & Credentialing Management
• Maintain a centralized credentialing and payer-contract database or tracking system.
• Track:
o Credentialing submission and approval dates
o Provider effective dates
o Recredentialing deadlines
o Contract renewal dates
o Fee schedules and reimbursement rates
o Government revalidation deadlines
o Provider licenses and certifications
o Outstanding payer issues
• Identify credentialing or enrollment issues that could result in out-of-network claims, denied claims, delayed reimbursement, or loss of network participation.
• Escalate significant payer or contracting issues to management.
• Work with billing and revenue-cycle staff to investigate claims affected by credentialing or enrollment issues.
Reporting & Administrative Responsibilities
• Prepare regular credentialing, contracting, and enrollment status reports for management.
• Maintain detailed documentation of payer communications and outstanding follow-up items.
• Identify delays, recurring payer issues, and opportunities to improve credentialing processes.
• Collaborate with providers, billing staff, leadership, and payer representatives.
• Maintain confidentiality of provider and organizational information.
• Ensure credentialing activities comply with payer requirements and applicable federal and state regulations.
• Perform additional credentialing and payer-contracting responsibilities as assigned.

Qualifications

Required Experience
• 3–5 years of healthcare provider credentialing, payer enrollment, or payer contracting experience preferred.
• Demonstrated experience with commercial insurance payer credentialing and contracting.
• Experience with Medicare and/or Medicaid enrollment and revalidation.
• Working knowledge of CAQH, NPPES, PECOS, NPI, taxonomy codes, and payer enrollment systems.
• Experience managing credentialing applications from initial submission through final approval.
• Experience communicating directly with payer credentialing and contracting departments.
• Strong understanding of provider enrollment, recredentialing, payer rosters, and effective-date management.

Skills
• Excellent organizational and project-management skills.
• Exceptional attention to detail and accuracy.
• Strong follow-up skills and ability to independently manage multiple outstanding applications.
• Ability to interpret payer contracts, fee schedules, enrollment requirements, and credentialing correspondence.
• Strong written and verbal communication skills.
• Ability to maintain detailed tracking systems and meet multiple deadlines.
• Strong analytical and problem-solving abilities.
• Proficiency with Microsoft Office, particularly Excel.
• Ability to work independently in a fast-paced healthcare environment.

Preferred Qualifications
• Experience credentialing psychiatrists, psychiatric nurse practitioners, physician assistants, psychologists, therapists, or other behavioral health professionals.
• Experience with multi-state provider credentialing and payer enrollment.
• Experience with behavioral health carve-outs and managed behavioral health organizations.
• Experience reviewing and maintaining commercial payer contracts and fee schedules.
• Experience with Medicare PECOS enrollment, reassignment, and revalidation.
• Experience with Medicaid enrollment and managed Medicaid plans.
• Familiarity with DrChrono or similar healthcare practice-management systems.
• Credentialing certification such as CPCS or CPMSM is a plus.

What We Are Looking For

We are looking for someone who owns the credentialing and contracting process from beginning to end. This person should not simply submit applications—they should proactively track applications, follow up with payers, resolve enrollment barriers, verify effective dates, maintain accurate provider rosters, and ensure providers are properly linked to the appropriate payer contracts.
The successful candidate will be persistent, organized, detail-oriented, accountable, and comfortable communicating directly with commercial and government payers. The ability to recognize how credentialing and contracting issues affect claims, reimbursement, and overall revenue-cycle performance is essential.