Manager, Credentialing

JOB TITLE: Credentialing Manager
FLSA STATUS (Exempt/Non-Exempt): Exempt
SUPERVISION RECEIVED: Reports to CEO
SUPERVISION EXERCISED: Credentialing Department

GENERAL STATEMENT OF DUTIES

Responsible for managing the credentialing department and overseeing the systems and processes associated with provider credentialing, recredentialing, licensing, privileging, payer enrollment, and provider onboarding. Ensures physicians and other healthcare providers are credentialed accurately and timely and that all required provider credentials, documentation, and information are maintained within the organization's credentialing systems. Partners with physicians/providers, Human Resources, Operations, Revenue Cycle Management, hospitals, health plans, and other internal and external stakeholders to facilitate provider onboarding, maintain ongoing credentialing compliance, and resolve credentialing-related issues.

ESSENTIAL FUNCTIONS

• Manages the timely and accurate completion of physician and other healthcare provider credentialing and recredentialing applications.

• Manages and supervises credentialing staff, including hiring, training, workload management, performance reviews, coaching, development, and ongoing performance management.

• Participates in and supports the provider onboarding process to ensure credentialing activities are initiated and completed within required timeframes.

• Oversees primary source verification and collection of required provider documentation, including professional licenses, board certifications, professional liability insurance, DEA registrations, National Practitioner Data Bank (NPDB) reports, and other required credentials.

• Ensures credentialing and recredentialing activities comply with applicable Joint Commission and NCQA standards, payer requirements, organizational policies, and other applicable credentialing requirements.

• Oversees provider enrollment and maintenance with Medicare, Medicaid, commercial health plans, and other applicable payers.

• Coordinates hospital and facility credentialing, privileging, and reappointment processes, as applicable.

• Ensures accurate collection, tracking, and documentation of provider expirable and renewal requirements within established timeframes.

• Maintains accurate and current provider information within CAQH and other applicable credentialing, payer, and provider databases.

• Ensures hospitals, health plans, medical groups, and other applicable entities are appropriately notified of provider demographic and practice changes.

• Oversees the processing of provider terminations from payer networks, hospitals, facilities, and other applicable entities.

• Collects, reviews, and audits disciplinary reports, OIG exclusion information, NPDB reports, state licensing board information, and other applicable sanction or monitoring reports and escalates concerns as appropriate.

• Provides consistent and timely follow-up on outstanding credentialing and recredentialing files and escalates delays, deficiencies, or other concerns to appropriate leadership when necessary.

• Establishes and maintains effective processes for credentialing file collection, document management, scanning, data capture, and data entry.

• Monitors the timeliness, completeness, and accuracy of credentialing documentation and provider data.

• Maintains current and archived provider credentialing records and ensures files are complete, accurate, confidential, and audit-ready.

• Prepares credentialing reports, adverse action documentation, provider status reports, and other credentialing reports as requested.

• Partners with Revenue Cycle Management and other departments to research and resolve claim denials or reimbursement issues related to provider credentialing or enrollment.

• Identifies trends in credentialing-related denials, delays, and discrepancies and develops action plans and process improvements to address identified issues.

• Applies performance improvement principles to continually evaluate and improve credentialing department processes, workflows, accuracy, and efficiency.

• Establishes and maintains effective communication with physicians/providers, hospitals, facilities, health plans, credentialing agencies, and internal departments.

• Serves as a resource to physicians/providers and leadership regarding credentialing, recredentialing, licensing, enrollment, and privileging requirements and status.

• Maintains the privacy and confidentiality of all provider professional and personal information obtained in the performance of job responsibilities.

• Performs other duties as assigned.

EDUCATION

• High school diploma or GED required.

• Associate's or bachelor's degree in Healthcare Administration, Business Administration, or a related field preferred.

• Certified Professional Medical Services Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS) certification preferred.

EXPERIENCE

• Minimum of two (2) years of experience in healthcare credentialing, provider enrollment, medical staff services, or a related credentialing function required.

• Prior supervisory or leadership experience preferred.

• Experience with physician and other healthcare provider credentialing and recredentialing preferred.

• Experience with payer enrollment, CAQH, Medicare, Medicaid, and commercial health plans preferred.

• Experience working within a multi-site physician practice or outpatient healthcare organization preferred.

KNOWLEDGE

• Knowledge of provider credentialing and recredentialing processes and regulatory standards.

• Knowledge of payer enrollment requirements and healthcare payer processes.

• Knowledge of primary source verification requirements and credentialing documentation standards.

• Knowledge of credentialing timelines, provider expirables, and renewal requirements.

• Knowledge of professional licensing, board certification, DEA registration, NPDB, OIG, and other applicable provider credentialing requirements.

• Knowledge of Joint Commission and NCQA credentialing standards, as applicable.

• Knowledge of CAQH and governmental and commercial payer enrollment processes.

• Knowledge of credentialing databases, computer systems, and Microsoft Office applications.

• Knowledge of changing payer and credentialing requirements within the healthcare industry.

SKILLS

• Strong leadership and staff management skills.

• Excellent verbal and written communication skills.

• Skill in establishing effective working relationships with physicians/providers, leadership, staff, payers, hospitals, and other internal and external stakeholders.

• Skill in organizing and prioritizing daily work assignments.

• Skill in managing multiple credentialing processes and competing priorities simultaneously.

• Skill in meeting demanding and time-sensitive deadlines.

• Strong attention to detail and accuracy.

• Skill in identifying and resolving credentialing, enrollment, and provider data discrepancies.

• Skill in organization, problem-solving, and process improvement.

• Skill in maintaining confidentiality and handling sensitive provider information appropriately.

ABILITIES

• Ability to independently manage and oversee the credentialing function.

• Ability to supervise, train, coach, and develop credentialing staff.

• Ability to establish and maintain effective working relationships with internal and external stakeholders.

• Ability to communicate effectively with physicians/providers, credentialing agencies, hospitals, health plans, leadership, and staff.

• Ability to organize and efficiently manage multiple credentialing activities and projects.

• Ability to exercise independent judgment and make appropriate decisions.

• Ability to identify potential credentialing delays or compliance concerns and escalate them appropriately.

• Ability to manage sensitive and confidential information and exercise appropriate discretion.

• Ability to meet established credentialing, recredentialing, enrollment, and renewal deadlines.

ENVIRONMENTAL WORKING CONDITIONS

• Normal office and outpatient healthcare environment.

PHYSICAL/MENTAL DEMANDS

• Requires sitting, standing, walking, and occasional bending and stretching associated with a normal office environment.

• Requires manual dexterity for computer, telephone, and other office equipment use.

• Requires sustained attention to detail and the ability to manage multiple priorities and time-sensitive deadlines.

• Requires the ability to communicate professionally and effectively with physicians/providers, leadership, staff, payers, hospitals, and external organizations.

ORGANIZATIONAL REQUIREMENTS

• HOPCo's Mission, Vision, and Values must be acknowledged and adhered to.

• Completes all required organizational training and education.

• Maintains compliance with all policies and procedures.