Credentialing Manager

The Credentialing Manager provides leadership and oversight for provider credentialing and recredentialing operations, ensuring processes and programs remain compliant with applicable regulatory, accreditation, contractual, and organizational requirements. This role is responsible for the ongoing development, implementation, monitoring, and continuous improvement of credentialing programs across all lines of business.

Key Responsibilities

• Lead, develop, and manage the Credentialing team, including hiring, training, performance management, and goal setting.
• Oversee end-to-end credentialing and recredentialing operations, including application review, primary source verification, and ongoing monitoring.
• Ensure compliance with NCQA, regulatory, contractual, and organizational standards, including turnaround times and reporting requirements.
• Maintain audit readiness and manage credentialing audits, corrective action plans, and remediation efforts.
• Develop, implement, and maintain credentialing policies, procedures, workflows, and delegation agreements.
• Lead Credentialing Committee activities, including file review, meeting facilitation, documentation, and follow-up actions.
• Serve as a subject matter expert and liaison for health plans, regulatory agencies, accreditation bodies, and internal stakeholders.
• Oversee credentialing systems, vendor performance, and provider data integrity; identify and implement system and process improvements.
• Monitor and report on operational metrics, productivity, and quality standards to identify trends and improvement opportunities.
• Lead process improvement and operational efficiency initiatives, including project planning and implementation.
• Support budget oversight and ensure effective use of resources.

• Bachelor’s degree in healthcare administration or other related field or a combination of equivalent education, training & experience. Candidates without a degree must have four (4) years of relevant professional experience in addition to the required five (5) years of credentialing experience. - REQUIRED
• Five years or more of previous experience in Credentialing working for a complex and diversified health plan, IPA, or other managed care organization - REQUIRED
• Three years or more experience managing personnel with at least two years supervising personnel in Provider Relations and/or Member Services - REQUIRED
• In depth knowledge of healthcare industry regulatory agencies, credentialing and provider directory standards including but not limited to CMS, NCQA, DMHC, DHCS, and HICE.
• Extensive understanding and experience using credentialing systems including the flow of credentialing and provider demographic information.
• Demonstrated computer skills; proficient with Microsoft Windows applications including but not limited to Excel, Word, Teams and Outlook.
• Demonstrated software skills in MD Staff - PREFERRED
• Familiarity with EPIC Tapestry
• Ability to travel/attend off-site meetings and conferences, when necessary
• CPMSM or CPCS - PREFERRED