Provider Qualifications Supervisor

CenCal Health•Santa Barbara, CA

1d•Onsite

About The Position

The Provider Qualifications Supervisor is responsible for the operational leadership, regulatory compliance, and continuous improvement of CenCal Health’s provider credentialing, privileging, and enrollment processes. This position combines the hands-on technical expertise of credentialing activities with people leadership, audit readiness, delegation management, and cross-functional collaboration to ensure full compliance with NCQA, DHCS, CMS, and other applicable regulatory and accreditation standards. This position serves as a key escalation point for complex provider qualification issues, delegated credentialing relationships, sanctions, and adverse actions, while also driving strategic initiatives to improve timeliness, accuracy, cost-effectiveness, and data integrity across credentialing and provider data programs. The Supervisor plays a critical role in survey readiness, performance management, and the development of scalable, compliant processes that support organizational growth and value-based care. This position works under the supervision of the Provider Credentialing and Data Integrity Manager.

Requirements

Proven leadership skills including motivating staff and performance management.
Able to multi-task in a fast-paced environment, managing multiple priorities and meeting deadlines.
Strong time management and organizational skills.
Able to use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.
Able to process a high volume of work and assume special projects over and above assigned responsibilities.
Strong leadership, organizational, and communication skills.
Ability to manage multiple priorities, meet deadlines, and ensure compliance with regulatory requirements.
Excellent problem-solving skills for resolving complex credentialing and site review issues.
Proficiency in Microsoft Office, virtual platforms, credentialing software.
Bachelor’s degree in Business Administration, Health Care Administration, Public Health, or a related field.
Three (3) years of experience in provider credentialing, accreditation, regulation, licensing, healthcare quality, or a closely related field.
Minimum of two (2) years of experience in a supervisory or leadership role.

Nice To Haves

Experience with credentialing and familiarity with NCQA, DHCS and CMS and other regulatory standards related to credentialing and provider quality management processes.
Familiarity with credentialing software systems, as well as Microsoft Office Suite.
CPCS strongly desired OR achievement of certification within 24 months.

Responsibilities

Provides day-to-day operational oversight and escalation management for credentialing and provider qualification functions, ensuring timely, accurate, and compliant execution aligned with organizational priorities and regulatory standards.
Ensures end-to-end oversight of credentialing, recredentialing, privileging, and enrollment processes, with accountability for eligibility determinations, documentation quality, and regulatory compliance.
Leads delegated credentialing oversight and audit readiness by managing agreements, monitoring performance, and coordinating corrective actions to maintain compliance with contractual and regulatory requirements.
Drives continuous improvement initiatives to enhance efficiency, reduce risk, and strengthen compliance across credentialing and provider qualification workflows using data-driven analysis.
Oversees the integrity, accuracy, and governance of provider credentialing data across systems, ensuring reliable reporting, effective controls, and timely resolution of discrepancies.
Builds and sustains a high-performing team through effective supervision, professional development, and stakeholder collaboration, while serving as a trusted subject matter expert and leader.
Supervise and coordinate the daily operations of provider credentialing, recredentialing, privileging, and enrollment activities to ensure compliance with regulatory requirements and service level agreements (SLAs).
Oversee credentialing queues and workload prioritization, adjusting resources and timelines to meet business demands and regulatory deadlines.
Serve as the escalation point for complex or high-risk provider applications, sanctions, adverse actions, audit findings, and delegated credentialing issues.
Ensure accurate, timely, and complete documentation of credentialing and provider qualification activities across all systems and files.
Monitor Compliance with Policies and Procedures through creation and maintenance of credentialing policies, workflows, and Standard Operating Procedures (SOPs) to ensure they are up-to-date and compliant with all applicable regulatory standards.
Participate in internal and external audits, ensuring that findings are addressed, corrective actions are implemented, and compliance is maintained.
Monitor and evaluate credentialing metrics, productivity reports, and audit outcomes to ensure that standards and regulatory requirements are consistently met.
Oversee the delegated credentialing process for delegated provider groups, ensuring that these entities adhere to the required documentation and quality standards.
Stay up to date with industry best practices, regulatory changes, and compliance requirements related to credentialing, and provider quality management to ensure CenCal Health remains compliant.
Guide and review the evaluation of initial and recredentialing applications, supporting documents, and primary source verifications to determine provider eligibility and compliance.
Ensure provider enrollment submissions by contracted providers, ensuring accuracy, timeliness, and alignment with regulatory and contractual standards.
Lead and support the preparation of complex practitioner-specific materials (e.g., committee reports, board memos, delegation reports) for decision-making bodies.
Ensure verification and tracking of expirables, sanctions, complaints, and adverse information in accordance with internal policy, accreditation and regulatory requirements.
Act as a resource for challenging credentialing cases, offering solutions and guidance for complex provider applications, site visits, and audit findings.
Oversee delegated credentialing relationships, including performance monitoring, ongoing compliance validation, and annual audit process.
Conduct pre-assessments and electronic audits for delegated entities.
Collaborate with internal audit, quality, compliance, and state standardization teams on shared delegation audits and regulatory reviews.
Participate in and support NCQA, DHCS, and other regulatory surveys and audits, ensuring findings are addressed and sustained compliance is achieved.
Continuously evaluate the credentialing and cross-functional processes to identify areas for improvement.
Adjust processes as needed to align with the organization's goals and regulatory changes.
Implement strategies to streamline workflows, increase efficiency, and reduce cycle times, while maintaining compliance with all regulatory requirements.
Act as a liaison between the credentialing and other internal departments to communicate quality improvement opportunities, share insights, and address concerns identified during credentialing activities.
Use metrics and performance data to track the effectiveness of process improvements and ensure adherence to service standards.
Represent the credentialing team in internal committees, including CenCal Health’s Peer Review & Credentialing Committee, quality committees and workgroups.
Oversee the quality of materials presented at credentialing meetings, ensuring agendas, supporting documents, and minutes are prepared timely and accurately.
Participate in or lead special projects as assigned by the Provider Credentialing and Data Integrity Manager or other leadership.
Drive continuous improvement initiatives to streamline credentialing and provider qualifications workflows while maintaining regulatory compliance.
Analyze productivity, turnaround time, audit outcomes, and performance metrics to identify risks, trends, and improvement opportunities.
Lead the development, maintenance, and enhancement of policies, workflows, SOPs, and governing documents to reflect regulatory changes and best practices.
Act as a liaison between Provider Services and cross-functional departments to align processes, resolve issues, and support organizational objectives.
Promote a culture of continuous improvement within the credentialing team.
Supervise and review credentialing and provider data across multiple systems, databases, and reporting tools to ensure accuracy, consistency, and integrity.
Oversee system access, workflows, and data controls related to credentialing and delegated processes.
Lead audits and reconciliations of provider qualification data between departments and systems, identifying discrepancies and driving resolution.
Ensure accurate and thorough documentation of all credentialing activities in the appropriate files and systems.
Provide direct supervision, coaching, mentoring, and performance management for assigned staff, including goal-setting, feedback, and evaluations.
Identify training needs and implement development plans to enhance staff competency, flexibility, and regulatory knowledge.
Foster a collaborative, accountable, and high-performing team culture aligned with CenCal Health’s values and leadership principles.
Monitor staff performance, providing regular feedback and conducting annual evaluations to assess productivity, accuracy, and compliance.
Address performance issues promptly to ensure continuous improvement and high-quality service.
Develop and deliver training, orientation, and educational materials for staff and providers related to credentialing, privileging, and recredentialing processes.
Maintain strong working relationships with internal leaders, external providers, delegated entities, and vendors.
Other duties as assigned.