- Department: Provider Services / RCM
- Reports To: Credentialing Manager / Director of Operations
- Job Type: Full-Time | US Shift
- Location: Chennai, India (Remote-US)
- Experience: 3–6 Years
- Education: Bachelor's / Associate's in Healthcare Administration or related field
- Key Speciality: Physician & Hospital Contracting
- Markets: US Healthcare - Multiple States
JOB SUMMARY
The Credentialing and Contracting Associate is responsible for managing the end-to-end credentialing process for healthcare providers across both physician (professional) and hospital/facility (institutional) settings, as well as facilitating payer enrollment and contract negotiations. This role ensures that providers and facilities are properly credentialed and contracted with insurance payers — allowing them to deliver services and receive appropriate reimbursement at all care settings.
The ideal candidate brings hands-on experience in both physician contracting (CMS-1500 / professional billing context) and hospital/institutional contracting (UB-04 / facility billing context), with a solid understanding of payer processes, fee schedule negotiation, and compliance requirements across both domains.
KEY RESPONSIBILITIES
1. Physician & Hospital Credentialing / Re-Credentialing
- Prepare, submit, and monitor initial credentialing and re-credentialing applications for individual physicians, non-physician practitioners (NPs, PAs, CRNAs), and facility/hospital-based providers
- Manage hospital credentialing and privileging for facility-based providers — including surgical, anesthesiology, radiology, emergency medicine, and hospitalist groups
- Submit hospital medical staff applications, manage committee review timelines, and coordinate with Medical Staff Offices (MSOs) for privilege letters
- Maintain up-to-date provider and facility files — licenses, certifications, board credentials, malpractice insurance, DEA registrations, accreditation documents
- Track all expiration dates and proactively manage renewals to prevent lapses in provider participation or hospital privileges
- Work with providers, facility administrators, and internal teams to collect required documentation and provider signatures
2. Physician Contracting - Professional Billing (CMS-1500)
- Initiate and complete payer enrollment for new individual physicians and non-physician practitioners with Medicare (PECOS), Medicaid, and all commercial payers
- Review, interpret, and negotiate physician fee schedules, reimbursement terms, and contract language with commercial payers - Aetna, BCBS, UnitedHealthcare, Cigna, Humana
- Identify underpayment opportunities by benchmarking contracted rates against Medicare allowables and national fee schedule data
- Manage the full cycle of physician provider agreements - initiation, negotiation, execution, and renewal
- Submit and track CMS-855I (individual physician) and CMS-855R (benefit reassignment) applications through PECOS
- Assist in joining existing group contracts or establishing new group agreements for multi-physician practices
3. Hospital / Facility Contracting — Institutional Billing (UB-04)
- Manage payer contracting and enrollment for hospital outpatient and inpatient facilities, ambulatory surgery centers (ASCs), skilled nursing facilities (SNFs), and other institutional providers
- Submit and track CMS-855A (institutional providers) and CMS-855B (clinics and group practices) applications
- Review and negotiate hospital-specific contract terms - DRG rates, APR-DRG groupings, per diem rates, case rates, and facility fee schedules
- Coordinate with hospital revenue cycle, case management, and utilization review teams to ensure contracted rates align with billing and documentation practices
- Manage Joint Commission, DNV, or other accreditation requirements as they relate to payer contracting and credentialing
- Track facility-level payer agreements, effective dates, and renegotiation windows across the hospital system or multi-facility group
4. Compliance & Data Management
- Ensure all credentialing and contracting activities are fully compliant with NCQA, CMS, URAC, The Joint Commission, and all applicable state and federal regulations
- Accurately maintain provider and facility records in credentialing platforms - CAQH ProView, PECOS, NPPES, Availity, and client-specific credentialing software
- Respond to payer audits, data requests, and re-verification notices within required timeframes
- Maintain strict confidentiality of all provider, facility, and organizational information at all times
- Monitor and report on credentialing and contracting compliance metrics — TFL risk, expiration tracking, privilege renewal rates
5. Cross-Functional Support
- Collaborate with billing, coding, scheduling, and AR teams to ensure credentialing and contracting status aligns with billing readiness for both professional and facility claims
- Provide regular updates to internal stakeholders on provider enrollment timelines, payer contract statuses, and upcoming renewals
- Support rate negotiation strategy by preparing comparative fee schedule analyses and payer reimbursement benchmarking reports
- Participate in internal meetings, credentialing committee discussions, and quality improvement initiatives
REQUIRED QUALIFICATIONS
Physician Credentialing & Contracting
- 3–6 years in physician credentialing and payer enrollment
- Hands-on PECOS - CMS-855I, CMS-855R submissions and tracking
- CAQH ProView profile management and attestation cycles
- Physician fee schedule review - Medicare RBRVS benchmark analysis
- Professional payer contract review and negotiation support
- Individual provider agreement initiation, execution, and renewal
- Medicare, Medicaid, Aetna, BCBS, UHC, Cigna, Humana enrollment
- Privileging and specialty-specific credentialing - MD, NP, CRNA, PA
Hospital / Facility Credentialing & Contracting
- Experience with hospital medical staff applications and MSO coordination
- CMS-855A and CMS-855B institutional enrollment experience
- Knowledge of DRG, APR-DRG, per diem, and facility fee schedule structures
- Experience with hospital contracting - inpatient, outpatient, ASC, SNF contracts
- Joint Commission / URAC / DNV accreditation and payer requirements awareness
- Multi-facility contract tracking and rate renegotiation coordination
- Medicaid managed care and state-specific hospital enrollment processes
- Hospital privilege letter tracking and committee review timeline management
Core Requirements (Both Tracks):
- Associate's or Bachelor's degree in Healthcare Administration, Business, or related field - or equivalent professional experience
- Proficiency with credentialing portals: CAQH, PECOS, NPPES, Availity, and payer-specific provider portals
- Strong working knowledge of HIPAA, NCQA, CMS, and state credentialing regulations
- Excellent attention to detail - ability to manage 50+ active applications simultaneously
- Strong written and verbal communication skills for payer representative interactions and internal reporting
- Proficiency in Microsoft Excel or Google Sheets for fee schedule analysis and tracking
PREFERRED SKILLS
- Experience in a medical billing or RCM outsourcing company managing multiple provider clients
- Knowledge of anesthesiology, hospital-based specialties, or facility billing nuances
- Prior experience in contract rate negotiation with commercial payers
- Familiarity with credentialing software such as CredentialStream, MD-Staff, symplr, or similar
- Understanding of IPA, ACO, and managed care network contracting models
- Multi-state credentialing experience - particularly Louisiana, California, Indiana, Texas, or New Jersey
- Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) preferred but not required
WHY HUMANXPERT
- Work on US healthcare accounts across multiple specialties and states - physician and hospital
- Direct exposure to contract negotiation, payer strategy, and credentialing leadership
- High-growth RCM company with expanding client base - real career progression
- Collaborative, vision-driven culture with strong leadership investment in every team member
To Apply:
- Send your resume and a brief cover note to: [Confidential Information]
- Subject Line: Application - Credentialing and Contracting Associate | [Your Name]
