Payer Contracting & Credentialing Manager

at  Associated Eye Care

Position Summary - Payer Contracting & Credentialing Manager
As a key member of the Associated Physician Partners revenue cycle team, the Payer Contracting & Credentialing Manager is responsible for overseeing, improving and ensuring a smooth payer contracting and credentialing process for APP clients, health services provider organizations. Responsibilities include negotiation of payer contract terms including governmental, private and commercial payers, financial analysis and interpretation of payer contracts and terms.

Payer Contracting & Credentialing Manager Essential Functions

• Negotiate and interpret client payer contracts; establishing financially beneficial contract terms and rates and ensuring contracts cover all services provided by APP clients
• Responsible for clinical and facility-based payer contracting, credentialing and pricing for APP clients
• Develop, organize, process contracts, and facilitate the approval process of all contract documents from pre-contract through post-signature phases
• Maintain a database of contracting and credentialing data, while continuously creating and updating processes and procedures, ensuring full utilization of systems and platforms
• Go to the marketplace for pricing information as available
• Manage and monitor processes and procedures that support payer credentialing, and re-credentialing, any expirable data management and delegated credentialing process to ensure compliance with state and federal regulations, individual health plan requirements, and regulations pertaining to Medicare and Medicaid programs.
• Coordinate with licensing agencies, insurance carriers, provider offices and other appropriate organizations to complete payer credentialing and credentialing
• Monitor entity specific rules, policies, and procedures, ensuring compliance with accrediting organizations and contracted payers
• Effectively communicate applicable payer updates, and detailed and complex topics such as healthcare industry specifics, market dynamics, trends, regulations and payer environment
• Evaluate and monitor contract performance to determine necessity for amendments, updates, or extensions
• Audit charge master in billing software system and update to reflect annual COLAs and rate increase as needed
• Pursue regular rate increases with contracted payers
• Perform reimbursement analysis including review of payer contracts, claim denials and contract variances
• Facilitate operationalizing payer contract requirements with cross-functional teams

SKILLS & KNOWLEDGE REQUIRED

• Knowledge of fee for service and/or fee for value reimbursement methods, delegated credentialing workflows, and working knowledge of all major payers
• Ability to design, develop, produce and apply performance reporting on areas of responsibility

Education & Licensing -Payer Contracting & Credentialing Manager

• Bachelor’s degree in business administration, healthcare management, or a related field
• OR, associate’s degree in above fields and minimum of five (5) years related work experience in healthcare contract management and negotiations require

Experience - Payer Contracting & Credentialing Manager

• 3-5 years in healthcare contract review, analysis and negotiation require

OTHER ESSENTIAL FUNCTIONS - PAYER CONTRACTING & CREDENTIALING MANAGER

• Must be available to work outside of regular working hours on occasion and able to travel to other AEC offices as needed
• Participates in department and company meetings, as requested
• Performs other duties as assigned

Education & Licensing -Payer Contracting & Credentialing Manager

• Bachelor’s degree in business administration, healthcare management, or a related field
• OR, associate’s degree in above fields and minimum of five (5) years related work experience in healthcare contract management and negotiations required

Experience - Payer Contracting & Credentialing Manager

• 3-5 years in healthcare contract review, analysis and negotiation required

Payer Contracting & Credentialing Manager Essential Functions

• Negotiate and interpret client payer contracts; establishing financially beneficial contract terms and rates and ensuring contracts cover all services provided by APP clients
• Responsible for clinical and facility-based payer contracting, credentialing and pricing for APP clients
• Develop, organize, process contracts, and facilitate the approval process of all contract documents from pre-contract through post-signature phases
• Maintain a database of contracting and credentialing data, while continuously creating and updating processes and procedures, ensuring full utilization of systems and platforms
• Go to the marketplace for pricing information as available
• Manage and monitor processes and procedures that support payer credentialing, and re-credentialing, any expirable data management and delegated credentialing process to ensure compliance with state and federal regulations, individual health plan requirements, and regulations pertaining to Medicare and Medicaid programs.
• Coordinate with licensing agencies, insurance carriers, provider offices and other appropriate organizations to complete payer credentialing and credentialing
• Monitor entity specific rules, policies, and procedures, ensuring compliance with accrediting organizations and contracted payers
• Effectively communicate applicable payer updates, and detailed and complex topics such as healthcare industry specifics, market dynamics, trends, regulations and payer environment
• Evaluate and monitor contract performance to determine necessity for amendments, updates, or extensions
• Audit charge master in billing software system and update to reflect annual COLAs and rate increase as needed
• Pursue regular rate increases with contracted payers
• Perform reimbursement analysis including review of payer contracts, claim denials and contract variances
• Facilitate operationalizing payer contract requirements with cross-functional team