Manager, Credentialing

JOB TITLE: Credentialing Manager 
FLSA STATUS (Exempt/Non-Exempt): Exempt 
SUPERVISION RECEIVED: Reports to CEO 
SUPERVISION EXERCISED: Credentialing Department 

GENERAL STATEMENT OF DUTIES 

Responsible for managing the credentialing department and overseeing the systems and processes associated with provider credentialing, recredentialing, licensing, privileging, payer enrollment, and provider onboarding. Ensures physicians and other healthcare providers are credentialed accurately and timely and that all required provider credentials, documentation, and information are maintained within the organization's credentialing systems. Partners with physicians/providers, Human Resources, Operations, Revenue Cycle Management, hospitals, health plans, and other internal and external stakeholders to facilitate provider onboarding, maintain ongoing credentialing compliance, and resolve credentialing-related issues. 

ESSENTIAL FUNCTIONS 

• Manages the timely and accurate completion of physician and other healthcare provider credentialing and recredentialing applications.  

• Manages and supervises credentialing staff, including hiring, training, workload management, performance reviews, coaching, development, and ongoing performance management.  

• Participates in and supports the provider onboarding process to ensure credentialing activities are initiated and completed within required timeframes.  

• Oversees primary source verification and collection of required provider documentation, including professional licenses, board certifications, professional liability insurance, DEA registrations, National Practitioner Data Bank (NPDB) reports, and other required credentials.  

• Ensures credentialing and recredentialing activities comply with applicable Joint Commission and NCQA standards, payer requirements, organizational policies, and other applicable credentialing requirements.  

• Oversees provider enrollment and maintenance with Medicare, Medicaid, commercial health plans, and other applicable payers.  

• Coordinates hospital and facility credentialing, privileging, and reappointment processes, as applicable.  

• Ensures accurate collection, tracking, and documentation of provider expirable and renewal requirements within established timeframes.  

• Maintains accurate and current provider information within CAQH and other applicable credentialing, payer, and provider databases.  

• Ensures hospitals, health plans, medical groups, and other applicable entities are appropriately notified of provider demographic and practice changes.  

• Oversees the processing of provider terminations from payer networks, hospitals, facilities, and other applicable entities.  

• Collects, reviews, and audits disciplinary reports, OIG exclusion information, NPDB reports, state licensing board information, and other applicable sanction or monitoring reports and escalates concerns as appropriate.  

• Provides consistent and timely follow-up on outstanding credentialing and recredentialing files and escalates delays, deficiencies, or other concerns to appropriate leadership when necessary.  

• Establishes and maintains effective processes for credentialing file collection, document management, scanning, data capture, and data entry.  

• Monitors the timeliness, completeness, and accuracy of credentialing documentation and provider data.  

• Maintains current and archived provider credentialing records and ensures files are complete, accurate, confidential, and audit-ready.  

• Prepares credentialing reports, adverse action documentation, provider status reports, and