Contracting and Credentialing Specialist

Billing Services

Full-time

Remote

The Contracting and Credentialing Specialist is responsible for managing the full lifecycle of payer contracting and provider credentialing for a nationwide portfolio of clinics and provider groups across all levels of care in behavioral health and substance use disorder (SUD) treatment. This role ensures that providers, facilities, and locations are properly enrolled, credentialed, and contracted with commercial and government payers (including state Medicaid programs, MCOs, and managed behavioral health organizations) so that claims can be billed and paid without disruption. The specialist works closely with billing, VOB (verification of benefits), and utilization review teams to resolve credentialing-related claim rejections and to keep provider data accurate and audit-ready across all client accounts.

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Key Responsibilities

Credentialing

• Manage initial credentialing and re-credentialing/revalidation for individual providers and organizational (facility) NPIs across multiple payers and states
• Maintain and update CAQH profiles, PECOS enrollment, and state Medicaid provider enrollment portals
• Track credentialing status, effective dates, and expirables (licenses, certifications, malpractice insurance, DEA, board certifications) using a centralized credentialing tracker
• Proactively identify and resolve expiring credentials before they lapse and disrupt billing
• Serve as the point of contact for payer credentialing departments, delegated credentialing entities, and provider enrollment specialists

Payer Contracting

• Negotiate, review, and manage payer contracts and fee schedules across all levels of care (e.g., detox, residential, PHP, IOP, OP, and other clinic-based services as applicable)
• Track contract effective dates, renewal terms, rate changes, and amendments across all payers and clients nationwide
• Support fee schedule build and maintenance in the practice management platform in coordination with billing configuration
• Monitor payer and state-specific regulatory and rate changes (e.g., Medicaid rate updates, modifier changes, program transitions) and translate them into contracting and enrollment action items
• Pursue in-network status with new payers as clients expand into new states, regions, or service lines

Provider Data Integrity & Audit

• Conduct routine provider data audits, cross-referencing practice management system data against credentialing trackers and payer records to identify taxonomy, NPI, name, or address discrepancies
• Resolve discrepancies proactively, before they result in claim rejections or denials
• Maintain accurate provider rosters for each client and ensure data consistency across all systems of record
  

Cross-Functional Collaboration

• Partner with the billing and collections teams to diagnose and resolve credentialing-related claim denials and rejections (e.g., provider not found, taxonomy mismatch, not enrolled with payer)
• Communicate credentialing and contracting timelines clearly to internal teams and external clients so billing expectations are set accurately
• Assist with onboarding new clients by assessing current credentialing/contracting status and building a remediation plan

Compliance & Documentation

• Ensure all credentialing files meet payer, state, and accreditation requirements
• Maintain organized, audit-ready documentation for all credentialing and contracting activity
• Stay current on payer-specific credentialing requirements and Medicaid behavioral health enrollment rules across all states and regions the company operates in

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Qualifications

Required

• 2+ years of experience in provider credentialing, payer enrollment, or contracting, ideally within healthcare or behavioral health/SUD settings
• Working knowledge of CAQH, PECOS, NPPES, and state Medicaid provider enrollment portals
• Familiarity with payer contract structures, fee schedules, and rate methodologies
• Strong attention to detail and comfort managing large volumes of provider data across spreadsheets/databases
• Excellent written and verbal communication skills for interfacing with payers, clients, and internal teams
• Experience managing credentialing/contracting for clinics or provider groups across multiple states and levels of care simultaneously

Preferred

• Experience with nationwide behavioral health/SUD credentialing across multiple levels of care (e.g., Medicaid MCOs, commercial payers, managed behavioral health organizations)
• Experience with a behavioral health EHR/practice management platform
• Understanding of ASAM levels of care and how they relate to payer contracting and rate structures
• Prior experience in an RCM/billing services company supporting external clients

Key Success Metrics

• Percentage of providers actively and correctly credentialed/enrolled per payer, per state
• Reduction in credentialing-related claim denials and rejections
• Turnaround time on new provider credentialing and payer contract execution
• Accuracy rate of provider data across systems (post-audit discrepancy rate)