Payer Relations and Credentialing Manager Remote

Achievement Behavior Services•Malverne, NY

2d•Remote

About The Position

Achievement Behavior Services is hiring a Payer Relations and Credentialing Manager to oversee provider credentialing and enrollment, insurance contracts, payer relationships, and related operational issues. The role supports insurance network growth across current and prospective states and works with leadership and teams across Clinical Leadership, Operations, Intake, Business Development, Authorizations, Staffing, and Revenue Cycle Management. The manager handles credentialing and recredentialing across commercial insurance, Medicaid, CHIP, and managed care plans; monitors enrollment requirements and deadlines; and resolves payer participation issues. The position oversees insurance contracts, amendments, fee schedules, reimbursement rates, renewals, and participation agreements, and supports leadership with contract negotiations and network decisions. The role also researches and coordinates new payer opportunities and multi-state expansion, monitors authorization requirements and insurance policy changes, and investigates complex issues involving credentialing, authorizations, contracting, reimbursement, payer policies, and claims. It maintains centralized trackers and detailed records of statuses, communications, deadlines, policy changes, and resolutions.

Requirements

Minimum 2 years of experience in healthcare credentialing, insurance contracting, authorization management, or revenue cycle operations.
Strong knowledge of commercial insurance, Medicaid, CHIP, and managed care enrollment and contracting processes.
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.

Nice To Haves

Experience working with ABA providers, behavioral health organizations, or pediatric healthcare services.
Experience with multi-state provider credentialing and insurance network expansion.

Responsibilities

Manage initial credentialing, recredentialing, and provider enrollment across commercial insurance, Medicaid, CHIP, and managed care plans.
Maintain 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 with insurance companies, including follow-up and escalation.
Coordinate credentialing across states, insurance networks, and organizational entities, and maintain a centralized status tracker.
Oversee insurance contracts, amendments, fee schedules, and participation agreements across 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 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.
Research payer networks, contracting opportunities, and participation requirements to support organizational growth and multi-state expansion.
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 tracker of payer opportunities, applications, contracts, and effective dates.
Collaborate with leadership, Operations, Intake, and Business Development to evaluate and implement payer opportunities based on financial and operational feasibility.
Work 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.
Monitor changes in insurance regulations, credentialing, authorizations, reimbursement policies, CPT codes, billing, and documentation requirements.
Contact insurers to investigate policy changes, clarify requirements, and confirm effective dates.
Evaluate the operational, clinical, and financial impact of payer updates and support 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.
Investigate and resolve complex insurance issues involving credentialing, authorizations, contracting, reimbursement, and payer policies.
Communicate 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 records of insurance communications, reference numbers, resolutions, and outstanding follow-ups.
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.