Manager, Credentialing

ChenMed

7d•$70,396 - $100,565•Onsite

About The Position

The Manager, Credentialing is responsible for managing credentialing projects and all aspects of provider credentialing within the organization. This role serves as a liaison between markets and payer credentialing staff, working with payers, center, market, and regional leadership, and HR Ambassadors to support an efficient, strategically defined credentialing program. The program is intended to improve processes for establishing new providers while reducing issues and gaps. The manager leads the credentialing team and oversees credentialing, recredentialing, licensing, provider enrollment, directory accuracy, quality improvement, audit readiness, delegated credentialing compliance, and Credentials Committee processes. The role also maintains credentialing systems, policies, metrics, and dashboards, and ensures PBM agreements and medical group structures are appropriately maintained.

Requirements

Five years of credentialing experience.
BA/BS degree in Health Services Administration or a closely related field, or additional experience above the minimum may be considered in lieu of the required education on a year-for-year basis.
Expert knowledge and understanding of multi-state Medicare, Medicaid, and commercial payor enrollment requirements.
Advanced knowledge of physician/provider credentialing requirements.
Understanding of delegated credentialing requirements from payors.
Ability to lead projects and organize and lead multidisciplinary project teams through associated project activities.
Ability to influence all levels of organizational leadership to drive process, strategy, and adherence to proper business protocols.
Computer application skills, including MS Word.
Skilled verbal and written communication.
Ability to work independently with limited supervision.
Spoken and written fluency in English.
Ability to exercise independent judgment.
Experience working in CAQH Pro-View and Medicare systems, including PECOS, NPPES, and I&A.

Nice To Haves

One year of experience in a lead or management capacity.
Certified Provider Medical Services Management (CPMSM) certification.
Certified Provider Credentialing Specialist (CPCS) certification.

Responsibilities

Lead the credentialing team day to day, including hiring, coaching, performance management, and workload distribution to meet turnaround standards.
Oversee the end-to-end credentialing and recredentialing process.
Run daily credentialing and recredentialing operations for providers, pharmacies, and dispensaries in line with NCQA primary source verification requirements.
Oversee the licensing program, including state licenses, DEA/CDS, and board certification, and ensure renewals are completed before expiration.
Oversee provider enrollment and directory accuracy through the Lead Enrollment Coordinator and Lead PCBM, and own status reporting for both.
Execute the credentialing quality improvement program, including file audits, baseline measurement, deficiency tracking, and corrective action follow-through.
Keep credentialing files audit-ready and coordinate file pulls and responses for payer and pre-delegation audits.
Execute CVO delegation requirements, including payer reporting, oversight deliverables, and ongoing compliance with delegation agreements.
Manage the Credentials Committee process, including file preparation, agendas, minutes, and follow-up on committee decisions.
Maintain the credentialing database in Verifiable and Workday and ensure data accuracy.
Coordinate the annual review and update of CVO policies and procedures.
Maintain team metrics and dashboards and report performance to RCM leadership.
Ensure Pharmacy Benefit Manager (PBM) agreements are updated and executed on time.
Establish and manage medical group structures, ensuring all entities are accurately enrolled in the appropriate health plan networks.
Perform other duties as assigned and modified at the manager’s discretion.