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.