Credentialing Manager

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

📋 Description

• Lead and manage the entire practitioner credentialing and recredentialing process in accordance with CMS, NCQA, state, Medicaid, and insurance standards.

• Supervise and guide a team of credentialing professionals tasked with provider credentialing.

• Oversee provider file inventory, team workflows, production targets, quality assurance, and credentialing turnaround times.

• Create tracking and reporting mechanisms for provider status, team performance, credentialing volume, and potential risks.

• Develop, implement, and uphold credentialing policies and procedures.

• Identify areas of inefficiency and spearhead process improvement initiatives.

• Ensure accurate provider status information is maintained in provider data management and credentialing systems.

• Manage credentialing correspondence, approvals, denials, information requests, and provider follow-up.

• Collaborate with data management and IT teams on credentialing system integration and operational enhancements.

• Investigate and resolve credentialing issues to prevent recurrence.

• Maintain documentation for the Credentialing Committee, manage meeting agendas, and present credentialing recommendations.

• Inform providers and internal stakeholders about changes in credentialing status.

• Oversee provider outreach, application submissions, documentation, and internal quality assurance processes.

• Train and support team members, Medical Directors, and health plan partners on credentialing processes and tools.

⛳️ Requirements

• Bachelor’s degree or an equivalent combination of education and relevant healthcare experience.

• At least 7 years of experience in a managed care organization or large health plan setting.

• Minimum of 5 years of hands-on provider credentialing and contracting experience.

• Proven experience in leading provider credentialing operations and managing team performance.

• In-depth knowledge of physician credentialing standards and requirements as set by CMS, NCQA, state agencies, and Medicaid programs.

• Experience with CredentialStream or a similar credentialing platform.

• Proficient in Excel and SharePoint.

• Demonstrated ability to manage high-volume credentialing workflows, provider file inventory, quality metrics, and operational deadlines.

• Experience in building, enhancing, or rectifying credentialing processes and tracking systems.

• Strong reporting and analytical capabilities, including the ability to monitor and interpret credentialing trends and performance.

• Excellent written and verbal communication skills, with the capability to work effectively across various organizational levels and with external partners.

• Proficient in Microsoft Office applications and credentialing management systems.

• Experience in a national or regional managed care organization or large health plan is preferred.

• Familiarity with SQL-related processes or working with SQL-supported reporting is preferred.

• Interest in utilizing AI, automation, bots, or agents to enhance operational efficiency is preferred.

• Proven success in implementing process improvements within a complex, high-volume credentialing setting is preferred.

• Must be eligible to work in the United States; visa sponsorship is not available.

🏝️ Benefits

• Comprehensive health insurance plans.

• Retirement savings options with company match.

• Opportunities for professional development and training.

• Flexible working hours and remote work options.

• Generous paid time off and holiday policies.