Credentialing Manager

What You'll Do

Supervisor Responsibilities

• Lead and manage a small group of Credentialing Interns, Associates, and Specialists, overseeing job assignments, performance reviews, and professional development while ensuring alignment with organizational goals.
• Approve timesheets, provide mentorship, and offer strategic support to optimize team performance and ensure operational success.

Credentialing

• Ensure streamlining of operational processes related to credentialing.
• Partner with the Senior Credentialing Manager to prepare and present comprehensive credentialing packets for the Credentialing Committee as needed, including flagged file reviews, coordination of logistics, and reporting on credentialing KPIs.
• Liaise with the Credentialing Verification Organization (CVO) and the Credentialing Supervisor to ensure the timely completion, downloading, and uploading of files, and maintain accurate system updates reflecting credentialing decisions.
• Support the Senior Credentialing Manager to proactively collaborate with the CVO, Credentialing Supervisor, and credentialing Specialists to address outreach improvements, resolve inconsistencies, and facilitate weekly meetings to enhance the credentialing process.

Re-credentialing

• Ensure a timely initiation of the re-credentialing process for the provider network with review of quality and complaint data as well as documentation and movement of providers into the process of re-credentialing to initiate the re-credentialing review.
• Identify non-engaging, zero-caseload providers and process them for administrative termination when unresponsive.
• Ensure a seamless and efficient re-credentialing process for the provider network, maintaining compliance with regulatory and organizational standards.
• Coordinate with the CVO to guarantee the timely review and completion of re-credentialing processes for all clinicians while ensuring the next re-credentialing cycle is accurately scheduled.

Delegation Management

• Support the Senior Credentialing Manager in maintaining and strengthening relationships with Enterprise clients and Account Management under delegated credentialing agreements, ensuring satisfaction and compliance with credentialing standards.
• Provide regular network update reports to Enterprise clients in accordance with delegated agreements.
• Partner with the Senior Credentialing Manager to liaise with the Business Development/Account Management team to secure new delegated contracting opportunities by completing and submitting pre-delegation enrollment packets, documenting and tracking progress and outcomes as required.
• Provide monthly roster reports to Enterprise clients as required with tracking and assisting with system loading for network participation for specialized plans.

Auditing and Compliance

• Conduct regular audits of the CVO's credentialing processes to ensure operational efficiency, accuracy, and compliance with internal and external standards.
• Conduct quarterly internal audits to validate the accuracy and efficiency of the Credentialing Program.
• Collaborate with Enterprise clients to provide data for annual, monthly, or ad hoc audits, ensuring transparency and compliance.

Licensing and Ongoing Monitoring Compliance Management

• Oversee the review of credentialed licenses to ensure all provider information is up-to-date and accurate, maintaining compliance with regulatory and organizational requirements.
• Support the Senior Credentialing Manager with documentation and reporting for ongoing monitoring requirements.

Process Improvement and Workflow Optimization

• Align with the Senior Credentialing Manager in the continuous review and refinement of credentialing workflows, ensuring the implementation of best practices and maximizing operational efficiencies within the credentialing program.
• Perform other related duties as assigned.

About You

• Bachelor's Degree required (Master's Degree preferred) or 7+ years of professional experience in credentialing or a related field.
• 4+ years of professional experience in a credentialing, compliance, or healthcare operations role, with proven experience in team leadership and process management.
• Strong background in managing credentialing operations, including experience working with Credentialing Verification Organizations (CVOs) and handling delegated credentialing agreements.
• Familiar with NCQA standards and guidelines as well as policy and contract review to ensure compliance with said standards.
• Demonstrated ability to manage cross-functional teams, lead projects, and streamline workflows to optimize efficiency.
• Excellent communication, organizational, and problem-solving skills, with a strong focus on collaboration with both internal and external stakeholders.
• Experience in conducting audits, maintaining compliance with regulatory standards, and implementing process improvements.
• Familiarity with credentialing software and systems, as well as proficiency in reporting on credentialing metrics.
• Proficient with Mac devices, Excel, Word, Google Suite (sheets, docs).