Credentialing Manager

Key Responsibilities:

• Maintain strict alignment with NCQA, URAC, Joint Commission, CMS, and state regulatory guidelines.
• Design, implement, and audit internal quality control processes to ensure zero gaps in provider files.
• Serve as the lead coordinator for all external facility and plan audits.

Team and Collaboration:

• Manage relationships with major commercial insurance plans, Medicare, and Medicaid.
• Collaborate closely with the Compliance, Billing, Legal, Clinical and Revenue operations teams to troubleshoot credentialing-related claim denials.
• Oversee the accuracy and security of the credentialing database.

Licensing and Compliance:

• Oversee the full lifecycle of state-level licensing, managing individual provider credentials and facility-level licenses.
• Ensure CAQH profiles, NPPES data, and state license renewals are updated systematically across the entire roster.
• Monitor key performance indicators (KPIs) like 'Days to Enroll' and proactively resolve complex application rejections to protect organizational cash flow.