Credentialing Manager

This is a fully remote position, open to applicants in United States.

📋 Description

• Provide strategic oversight for credentialing, licensing, recredentialing, privileging, and payer enrollment operations.

• Establish standards, policies, and performance metrics for the department.

• Ensure adherence to federal, state, payer, and accreditation regulations.

• Act as the escalation point for complex cases, audits, and inquiries from payers or regulatory bodies.

• Monitor regulatory changes and revise policies and processes accordingly.

• Oversee both internal audits and external reviews conducted by payers or regulatory agencies.

• Manage credentialing and licensing staff, including recruitment, training, coaching, and performance assessment.

• Develop scalable staffing models that align with client growth and service demand.

• Conduct performance evaluations and facilitate professional development planning.

• Create SOPs, training materials, and frameworks for quality assurance.

• Lead the implementation and enhancement of credentialing technology platforms and automation processes.

• Establish systems that are audit-ready for documentation, tracking, and compliance reporting.

• Ensure adherence to primary source verification and documentation standards consistently.

• Collaborate with executive leadership to develop, price, and position credentialing and licensing services.

• Contribute to marketing materials, proposals, and client presentations.

• Assist in client discovery calls, solution design, and contract development.

• Identify new market opportunities and avenues for service line expansion.

• Work collaboratively with revenue cycle, compliance, legal, and operations teams.

• Serve as a subject matter expert in best practices related to credentialing and licensing.

• Align credentialing processes with billing, appeals, eligibility, and denial management functions.

• Provide executive-level oversight regarding credentialing-related impacts on revenue performance.

⛳️ Requirements

• Bachelor's degree in healthcare administration, Business, or a related field (or equivalent experience).

• 5 to 8+ years of experience in provider credentialing, licensing, and payer enrollment.

• In-depth knowledge of Medicare, Medicaid, managed care, and commercial payer requirements.

• Experience with quality management frameworks.

• Proven ability to build, manage, and lead operational teams.

• Familiarity with credentialing and PSV technology platforms.

• Strong time management and organizational skills.

• Knowledge of NCQA credentialing standards is preferred.

• CPCS, CPMSM, or equivalent professional credentialing certification is preferred.

• Willingness to travel between facilities as needed.

• Ability to perform sedentary work and meet the specified physical demands.

🏝️ Benefits

• Exempt employment.

• Professional development planning.

• Remote work arrangement.