Payor Relations and Credentialing Specialist

Attention all heroes! Ready to embark on a career journey that not only propels your professional growth but also leaves a lasting impact on families and children in your community? Your quest ends here – join the incredible team at Woven Care (formerly Shandy Clinic), where your heroic potential meets purpose!
We are looking for a collaborative and highly motivated Payor Relations and Credentialing Specialist with a strong background in the Colorado healthcare market. In this dual role, you will be responsible for managing relationships with payors and overseeing the credentialing process while also leading various projects within the billing department and supporting the CEO and Leadership Team from time to time on strategic initiatives, special projects, and high-priority assignments critical to the success of the organization.

Compensation Range:

• $55,000 – $70,000/year

Essential Duties and Responsibilities - Credentialing Management:

• Lead the end-to-end credentialing process with insurance payors, ensuring our providers meet all necessary requirements for participation
• Collaborate with internal teams to collect, verify, and evaluate the qualifications, licenses, certifications, and other credentials of the provider
• Review documentation for accuracy and completeness, addressing any discrepancies
• Maintain excellent, up-to-date, and accurate provider credentialing files and assist with maintaining current provider NPI registry and other databases. Ensuring data integrity and compliance with privacy laws
• Facilitate timely submission and approval of credentialing applications
• Identify and recommend improvements to the credentialing process to enhance efficiency and effectiveness
• Conduct quality assurance reviews to ensure that credentialing processes meet established standards and requirements
• Generate and analyze reports related to credentialing activities, providing insights to management and stakeholders

Essential Duties and Responsibilities - Project Leadership:

• Oversee special projects and initiatives, ensuring they are completed on time and within budget
• Build and lead cross-functional project teams when necessary, providing clear direction and support
• Initiate and lead projects related to billing, credentialing process improvement, efficiency, and automation
• Collaborate with cross-functional teams to implement and optimize credentialing and payor relations systems and processes
• Provide regular updates on project progress to leadership

Essential Duties and Responsibilities - Payor and External Relations Relationship Management:

• Cultivate and maintain positive relationships with payors to facilitate efficient communication and issue resolution
• Represent the CEO and Leadership Team in various capacities, fostering positive relationships on behalf of the organization
• Lead negotiations for commercial payor to ensure favorable terms and conditions
• Collaborate with the leadership team to review and finalize contracts
• Stay informed about payor policies, fee schedules, and industry trends
• Build and maintain relationships with external partners, stakeholders, and key industry players

Essential Duties and Responsibilities - Market Expertise:

• Demonstrate a deep understanding of the Colorado healthcare market, including knowledge of key players, competitive landscape, and market trends
• Leverage existing relationships and networks to enhance contract negotiation outcomes
• Maintain and enhance the brand image of the healthcare organization

Essential Duties and Responsibilities - Data Analysis

• Conduct data analysis related to payor contracts, provider credentialing, and reimbursement rates
• Identify opportunities for improvement and optimization in contract negotiations and credentialing processes
• Prepare reports and presentations for leadership on contract performance and credentialing metrics

Essential Duties and Responsibilities - Quality Assurance

• Conduct regular audits to ensure the accuracy and completeness of provider credentialing files
• Implement quality assurance measures to enhance the efficiency and effectiveness of credentialing processes

Essential Duties and Responsibilities - Compliance:

• Stay abreast of healthcare industry regulations, accreditation standards, and licensing requirements related to credentialing
• Ensure all credentialing activities comply with applicable laws, regulations, and organizational policies

Minimum Qualifications (Knowledge, Skills, and Abilities):

• Bachelor’s degree in Healthcare Administration, Business, or related field.
• Proven experience in Insur