Credentialing Manager

Position Summary

The Credentialing Manager is responsible for leading the Credentialing and Provider Data teams and is accountable for overseeing systems, processes, and procedures that ensure compliance with the company's credentialing policies and standards, health plan partner requirements, and all applicable regulatory and accreditation guidelines.

This role oversees the initial and ongoing credentialing and enrollment processes for all clinicians and providers. The Credentialing Manager is responsible for maintaining credentialing databases and online systems, ensuring provider files remain accurate and current, managing health plan enrollments and reappointments, and coordinating medical staff privilege applications with contracted facilities and clinics. In addition, the Credentialing Manager oversees the Provider Data function to ensure that non-contracted provider information is entered accurately and maintained in compliance with claims processing, authorization workflows, and regulatory requirements.

Responsibilities and Duties

• Ensure compliance with the company's credentialing, recredentialing, and provider data management policies and procedures, as well as all applicable state, federal, accreditation, and health plan credentialing requirements.
• Collaborate with organizational leadership to develop, implement, and standardize credentialing policies, procedures, and criteria across the company.
• Maintain accurate, complete, and up-to-date credentialing files and records.
• Ensure the integrity and accuracy of credentialing databases, reporting systems, and provider records.
• Oversee the accuracy and maintenance of non-contracted provider data.
• Monitor external credentialing databases and systems, including CAQH, PECOS, and other regulatory resources, ensuring provider information is current and readily accessible.
• Verify that credentialing files are complete and compliant prior to presentation to the Credentialing Committee.
• Provide guidance and consultation to leadership and the Credentialing Committee regarding credentialing, clinical qualifications, reappointments, and related matters.
• Oversee compliance with delegated credentialing agreements, health plan requirements, and credentialing audit activities.
• Manage the review and tracking of adverse actions, sanctions, licensure restrictions, disciplinary actions, and credentialing-related complaints.
• Recruit, interview, hire, train, and develop credentialing staff, while providing ongoing education regarding new regulations, guidelines, and process improvements.
• Monitor and manage staff workloads and credentialing workstreams, including onboarding, credentialing, pharmacy credentialing, medical staff privileging, Medicare and Medicaid enrollments, credentialing committee activities, and health plan enrollments.
• Evaluate staff performance and participate in performance management activities, including coaching, corrective action, performance improvement plans, and personnel decisions when necessary.
• Conduct routine audits of credentialing files, databases, and team work products to ensure compliance and quality standards are met.
• Oversee initial applications and reappointments for Medicare, Medicaid, hospitals, ambulatory surgery centers, and managed care organizations.
• Develop and present regular operational reports, metrics, and analyses regarding credentialing activities, including approvals, denials, appeals, and compliance performance.

Additional Responsibilities

• Monitor licensure renewals, certifications, and other time-sensitive credentials, ensuring updated documentation is received, processed, and distributed to facilities and healthcare partners as required.
• Coordinate and facilitate health plan meetings when needed.
• Partner with leadership to identify, implement, and maintain credentialing best practices.
• Serve as a primary point of contact for facilities, health plans, internal departments, and external stakeholders regarding credentialing matters.
• Collaborate with leadership to maintain accurate provider rosters and ensure timely submissions to health plans and other entities.
• Provide direct management and supervision of credentialing personnel and departmental operations.
• Attend meetings with payer representatives to address credentialing, enrollment, and operational issues as requested.
• Respond to internal and external requests regarding provider credentialing and licensing status.
• Prepare reports, presentations, and analyses for leadership as requested.
• Perform responsibilities in accordance with credentialing and recredentialing policies and procedures.
• Perform other duties as assigned to support departmental and organizational objectives.

Education and Experience Requirements

• Minimum of five (5) years of healthcare credentialing experience in a managed care environment, including at least one (1) year of supervisory or leadership experience.
• Bachelor's degree in Business Administration, Healthcare Administration, or a related field required.
• Strong knowledge of web-based credentialing systems and applications; experience with MD-Staff or similar credentialing software preferred.
• Working knowledge of NCQA, AAAHC, The Joint Commission (TJC), AOA, URAC, and other applicable accreditation, compliance, and regulatory standards.
• Demonstrated database management and reporting skills, including data analysis, querying, reporting, and document generation.
• Certified Provider Credentialing Specialist (CPCS) designation preferred.
• Strong organizational, analytical, communication, and leadership skills with the ability to manage multiple priorities in a fast-paced healthcare environment.