Licensing and Credentialing Manager

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

📋 Description

• Manage the relationship with the CertifyOS vendor, including oversight of budget and renewal negotiations.

• Supervise the daily operations performed by CertifyOS on behalf of Brightline, ensuring adherence to defined service levels.

• Oversee provider licensing and license renewals across various states.

• Guarantee timely submission, tracking, and renewal of provider licenses.

• Evaluate vendor performance against set service level agreements (SLAs).

• Collaborate with internal stakeholders to ensure providers are licensed prior to their scheduled start dates.

• Identify and implement improvements in licensing workflows through automation and process optimization.

• Maintain precise licensing records and ensure compliance with all state licensing board regulations.

• Manage all activities related to commercial, Medicaid, and managed Medicaid payer credentialing.

• Personally oversee the process of provider enrollment, re-credentialing, and payer applications from submission to approval.

• Monitor credentialing status and proactively address enrollment delays.

• Ensure that providers are credentialed and billable before they deliver patient care whenever feasible.

• Keep complete and accurate documentation for credentialing.

• Track re-credentialing timelines to avert credentialing lapses.

• Oversee payer roster management for all contracted health plans.

• Ensure that provider roster submissions are accurate, timely, and aligned with payer systems.

• Coordinate updates involving provider additions, terminations, demographic changes, tax ID alterations, and location modifications with contracted payers.

• Conduct regular audits of the payer roster to identify and rectify discrepancies.

• Collaborate with Revenue Cycle teams to address billing issues arising from roster inaccuracies.

• Establish standardized processes for roster maintenance as the organization grows.

• Cultivate and maintain strong relationships with credentialing representatives from commercial and government payers.

• Lead monthly operational meetings with payers, focusing on credentialing escalations, enrollment turnaround times, provider roster accuracy, re-credentialing performance, and process improvement opportunities.

• Act as the primary escalation point within the organization for payer credentialing concerns.

• Represent the licensing and credentialing function in cross-functional forums, advocating for the function's priorities and status rather than merely coordinating within it.

• Collaborate closely with various teams to resolve payer-related issues affecting provider enrollment.

• Assist in developing delegated credentialing programs with contracted payers.

• Work alongside Compliance and Quality teams to ensure that delegated credentialing requirements are fulfilled.

• Coordinate audits conducted by payers and maintain readiness for such audits.

• Own and report on the key metrics that determine the effectiveness of the function, including days to credential, on-time license renewal rate, and payer roster accuracy rate.

• Define the processes, documentation, and workflows that the function currently relies on, ensuring they can withstand the growth in provider volume, state coverage, and payer relationships.

• Proactively present metric trends and process gaps to leadership, rather than waiting for issues to lead to delays.

⛳️ Requirements

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

• Over 5 years of experience in provider licensing and payer credentialing.

• Strong knowledge of CAQH, NPPES, PECOS, Medicare enrollment, Medicaid enrollment, and commercial payer credentialing.

• Excellent communication, negotiation, and relationship management skills.

• Strong problem-solving abilities and experience in managing escalations.

• Capability to handle multiple priorities while maintaining a keen attention to detail.

• Experience leading cross-functional initiatives that enhance operational performance.

• Experience in managing multi-state provider licensing.

• Experience in managing vendor relationships and delegated credentialing programs.

• Familiarity with CertifyOS or similar credentialing software is preferred.

• Preferred experience with credentialing providers through commercial and Medicaid payers.

• Experience in managing payer roster submissions and ensuring provider directory accuracy.

🏝️ Benefits

• Medical, Dental, Vision, Long-Term Disability, Life Insurance, Flexible Spending Account, and 401k.

• 12 Company Holidays + Floating Holidays, Holiday Shutdown, Flexible Time Off, Parental Leave.

• Health and Wellness Stipend, Home Office Reimbursement, and Professional Development Reimbursement.

• Stock Options.