Position Summary:

The Credentialing Manager is responsible for overseeing all aspects of the provider credentialing, recredentialing, and enrollment processes, including delegated credentialing agreements and maintaining compliance with NCQA (National Committee for Quality Assurance) accreditation standards. This role ensures that credentialing activities are performed in a timely, accurate, and regulatory-compliant manner, supporting quality care delivery and network integrity.

Essential Duties and Responsibilities:

• Manage and lead the end-to-end credentialing, recredentialing, and enrollment processes for all providers and facilities within the organization.


• Maintain and ensure compliance with all NCQA credentialing standards and guidelines.


• Oversee delegated credentialing arrangements, including the preparation, execution, monitoring, and auditing of delegated entities.


• Serve as the primary liaison with health plans, delegated entities, and regulatory agencies regarding credentialing and enrollment matters.


• Coordinate and lead internal credentialing committee meetings, including preparation of files for review and documentation of decisions.


• Lead and conduct internal audits and file reviews to ensure credentialing and enrollment files meet accreditation and payer standards.


• Develop and maintain credentialing and enrollment policies and procedures that align with NCQA and other regulatory requirements.


• Supervise credentialing and enrollment staff; provide training, mentoring, and performance evaluations.


• Collaborate with cross-functional departments such as Compliance, Quality, Revenue Cycle Management and Provider Relations to support integrated credentialing and enrollment processes.


• Manage credentialing and enrollment databases, including updates, reporting, and accuracy of provider data.


• Prepare for and lead credentialing and enrollment-related accreditation surveys and audits.


• Monitor changes in credentialing standards and payer requirements and ensure timely updates to processes.

Qualifications:

**Required:**

• Minimum of 5 years of progressive experience in medical staff services or health plan credentialing and enrollment.


• At least 2 years of experience in a management or supervisory role.


• Direct experience managing delegated credentialing arrangements.


• Demonstrated knowledge of NCQA credentialing standards and survey preparation.


• Experience with credentialing software platforms


• Proficiency in Microsoft Office Suite (Word, Excel, Outlook, PowerPoint).

**Preferred:**

• Bachelor's degree in Healthcare Administration, Business Administration, or a related field.


• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) through NAMSS.


• Experience working with managed care organizations or clinically integrated networks.

Key Competencies:

• Strong leadership and team-building skills.


• Excellent attention to detail and organizational ability.


• Analytical and problem-solving skills.


• Strong written and verbal communication skills.


• Ability to manage multiple priorities and deadlines in a fast-paced environment.

Work Environment:

This role may be remote, hybrid, or office-based depending on organizational needs. It may require occasional travel for meetings, audits, or site visits.