Credentialing Manager

Alma•Angle, MN

12d•Remote

About The Position

We’re looking for a leader with significant experience in healthcare credentialing, compliance, and process improvement. The Credentialing Manager is a critical role responsible for ensuring the organization's audit readiness and adherence to all regulatory and contractual requirements related to delegated credentialing. This individual will develop and own the quantifiable Compliance Scorecard, manage payer audit cycles, and lead high-impact initiatives to improve overall RCM efficiency and compliance for our platform.

Requirements

Robust Credentialing Leadership: 6+ years of progressive experience in healthcare credentialing, with a significant portion dedicated to managing delegated functions
Delegated Credentialing Expertise: Deep, demonstrated experience supporting and managing delegated credentialing agreements, including familiarity with pre- and post-delegation audit requirements and payer submission processes
NCQA Proficiency: Deep understanding and practical experience with NCQA standards and their application to both credentialing files and quality committee structure
RCM Compliance & Behavioral Health Knowledge: Strong working knowledge of the Revenue Cycle Management process and the regulatory nuances specific to mental/behavioral health services (e.g., medical necessity documentation)
Compliance Measurement: Proven experience establishing, monitoring, and reporting compliance KPIs and scorecards
Project Management & Organization: Exceptional organizational and project management skills with a demonstrated ability to manage complex, detailed, and timeline-driven compliance projects independently
Proven ability to interpret complex regulatory language (NCQA, CMS, etc.) and translate it into operational workflows
6+ years of progressive experience in healthcare credentialing, with a focus on managing delegated functions

Nice To Haves

Professional Certification: CPCS (Certified Provider Credentialing Specialist) or CHPC (Certified in Healthcare Privacy and Compliance)
Experience in the Mental Health/Behavioral Health sector, understanding specific parity requirements and documentation rules
Experience working in a high-growth healthcare technology or start-up environment

Responsibilities

Audit & NCQA Compliance Ownership
Delegation Audit Management: Serve as the subject matter expert and primary liaison for all insurance payer audits related to delegated credentialing agreements
NCQA Standard Implementation: Implement and maintain NCQA standards and requirements across all credentialing policies and procedures to uphold accreditation readiness and quality assurance
Compliance Scorecard & KPIs: Design, implement, and maintain the Compliance Scorecard and KPIs for credentialing and RCM, demonstrating measurable improvement year-over-year
Audit Preparedness: Ensure the organization is prepared for annual audits by developing a playbook and ensuring improvements based on any previous Corrective Action Plans (CAPs)
Policy & Regulatory Monitoring: Work with Legal and Compliance to monitor changes in payer, state, and federal laws and rapidly update internal policies and Standard Operating Procedures (SOPs) accordingly
RCM Integrity and Process Improvement
RCM Compliance Leadership: Lead compliance efforts within the RCM division, focusing on the regulatory intersections between credentialing, enrollment, and claims processing
Efficiency & Scalability: Identify and eliminate bottlenecks in the Credentialing and RCM workflows, specifically targeting root causes of claim denials and credentialing delays to improve the Clean Claim Rate
Leadership & Cross-Functional Management
Partner Oversight: Oversee the performance of any Credentials Verification Organization (CVO) partners and internal support partners to ensure their work meets NCQA and organizational quality standards
Compliance Training: Ensure annual required trainings are completed for all RCM and Credentialing staff
Committee Support: Facilitate and support the Credentialing Committee, ensuring committee decisions are documented and adhered to in alignment with all policies and procedures
Execution-Oriented Mindset: Act as a hands-on individual contributor when necessary, diving into operational details, troubleshooting issues, and executing complex tasks to drive continuous improvement

Benefits

We’re a remote-first company
Health insurance plans through Aetna (medical and dental) and MetLife (vision), including FSA and HSA plans
401K plan (ADP)
Monthly therapy and wellness stipends
Monthly co-working space membership stipend
Monthly work-from-home stipend
Financial wellness benefits through Northstar
Pet discount program through United Pet Care
Financial perks and rewards through BenefitHub
EAP access through Aetna
One-time home office stipend to set up your home office
Comprehensive parental leave plans
12 paid holidays and 1 Alma Give Back Day
Flexible PTO