The Credentialing Manager leads the end to end credentialing, privileging, and payer enrollment function for the Managed Service Organization. This role ensures timely, compliant provider onboarding while maintaining high standards of operational accuracy, audit readiness, and service excellence.

This is a player coach role responsible for directly managing complex credentialing cases while leading, developing, and holding accountable a credentialing team. The Manager builds scalable processes, monitors performance metrics, and serves as the primary escalation point for high impact or time sensitive matters.

Essential Duties & Responsibilities

Credentialing and Enrollment Operations

• Oversee full lifecycle credentialing, re-credentialing, privileging, and payer enrollment for all providers
• Personally manage complex, escalated, or high priority credentialing cases
• Ensure timely submission, tracking, and completion of all payer and facility applications
• Maintain active and compliant CAQH profiles and NPI registrations
• Track and manage renewals including licenses, DEA, board certification, and malpractice coverage
• Support new state launches including business address setup and expedited payer coordination

Compliance and Audit Readiness

• Ensure adherence to NCQA, CMS, URAC, Joint Commission, and state specific requirements
• Oversee primary source verification and documentation standards
• Maintain audit ready provider files and document retention practices
• Validate credentialing related expenses and malpractice coverage compliance

Team Leadership and Player Coach Expectations

• Provide day to day leadership, coaching, and workload management for credentialing specialists
• Set clear productivity, turnaround time, and quality expectations
• Conduct regular one on one meetings, team meetings, and performance evaluations
• Review work for accuracy and completeness and address performance issues promptly
• Develop team capabilities through training and process documentation
• Approve timecards and PTO and manage staffing allocation based on volume
• Model urgency, accountability, and provider centered service while remaining hands on in operational execution

Workflow and Process Optimization

• Design, implement, and refine scalable credentialing workflows and standard operating procedures
• Monitor turnaround times, application status, and enrollment effective dates
• Identify bottlenecks and implement process improvements
• Evaluate tools and systems to enhance efficiency and accuracy
• Contribute to long term scalability planning and staffing forecasts

Cross Functional Collaboration

• Partner with Talent Acquisition and People Operations to support seamless provider onboarding
• Collaborate with Billing and Accounts Receivable teams to resolve credentialing related denials or reimbursement delays
• Provide proactive updates to Operations and Clinical Leadership on credentialing status and risks
• Support contracting efforts when credentialing impacts payer participation

Reporting and Analytics:

• Produce recurring reports for leadership on credentialing pipeline status, turnaround times, bottlenecks, and risks.
• Track and analyze KPIs such as:
  • Application completion timelines
  • PSV accuracy
  • Enrollment effective dates
  • Volume by provider type
• Identify trends and recommend process improvements.

Compliance and Regulatory Oversight:

• Maintain up to date knowledge of payer requirements, state regulations, accreditation standards, and credentialing best practices.
• Ensure the department remains compliant with NCQA, URAC, Joint Commission, and state/federal rules.
• Prepare the team for audits and participate in internal or external audit processes.

Qualifications

Work Experience and Education

• Bachelor’s degree preferred; relevant experience may substitute
• CPCS certification strongly preferred
• Minimum three years of credentialing experience including payer enrollment and privileging
• Prior supervisory or team lead experience required

Skills and Competencies

• Strong knowledge of NCQA, CMS, and payer credentialing standards
• Proficiency with Google Suite, Excel or Sheets, credentialing databases, and workflow tools
• Exceptional organizational skills and attention to detail
• Ability to manage multiple deadlines in a high volume environment
• Strong judgment, problem solving ability, and professional communication skills
• Ability to lead with accountability while maintaining strong provider relationships