Credentialing Manager

Overview

JOB SUMMARY: The Credentialing Manager is responsible for overseeing and managing the organization’s provider credentialing and recredentialing processes in accordance with regulatory, contractual, and accreditation standards. This role ensures the accuracy, completeness, and timeliness of credentialing activities across all lines of business, including Commercial, Medicare, and Medi-Cal. The Credentialing Manager works closely with internal departments, delegated entities, providers, and external agencies to support network compliance, delegated oversight, and operational readiness.

Additionally, the Credentialing Manager leads credentialing operations for the medical clinic and IPA, oversees staff, maintains credentialing systems, ensures compliance with NCQA and CMS standards, supports payor enrollment, and drives continuous process improvement to reduce onboarding delays and mitigate revenue and compliance risks.

Serves as the organization’s credentialing and delegated oversight subject-matter expert. Ensures provider network readiness, audit compliance, and timely payor activation to prevent reimbursement delays. Functions in a dual environment (clinic + IPA/MSO), managing differing regulatory and operational requirements. Represents the organization in health plan audits, oversight reviews, and credentialing committee governance. Leads credentialing staff while driving process improvements, accuracy, and standardization.

The following are exemplary essential job duties and responsibilities and are not intended to represent an all-inclusive listing of related essential functions of the position.

• Credentialing Leadership & Operations
  Lead and manage all aspects of provider credentialing, recredentialing, and privileging for physicians, allied health professionals, and facilities.
• Ensure compliance with NCQA, CMS, DMHC, DHCS, and health plan-specific requirements, as well as internal organizational policies and procedures.
• Oversee primary source verification, file completeness, and adherence to credentialing timelines.
• Maintain current and accurate credentialing data across systems (e.g., CAQH, MD-Staff, Verity Stream/Credential Stream, Modio, or other platforms).
• Monitor expiring credentials (licenses, DEA, malpractice insurance, board certification, etc.) and ensure timely re-verification.

• IPA & Delegated Credentialing Oversight
  Oversee the preparation, accuracy, and submission of credentialing and roster files to contracted health plans and delegated entities.
• Serve as the primary point of contact for delegated credentialing audits, regulatory reviews, and health plan oversight visits.
• Ensure delegated activities meet NCQA, DHCS, Medicare Advantage, and health plan delegation requirements.
• Maintain delegated credentialing policies, audit tools, dashboards, and corrective action plans when necessary.

• Credentialing Committee & Governance
  Manage the Credentialing Committee process, including preparing agendas, presenting files, creating minutes, documenting decisions, and following up on action items.
• Ensure committee processes meet organizational bylaws, regulatory requirements, and accreditation standards.

• Payor Enrollment & Network Readiness
  Oversee payor enrollment and revalidation with Medicare (PECOS), Medi-Cal (PAVE), NPPES, CAQH, and commercial plans to support timely provider onboarding.
• Collaborate with Revenue Cycle, Contracting, Provider Relations, and Operations to ensure providers are loaded correctly and activated on schedule.
• Support provider directory accuracy and network integrity across all participating health plans.

• Workflow Optimization & Compliance
  Develop, implement, and monitor credentialing workflows that improve efficiency, accuracy, and turnaround times.
• Create and maintain SOPs, audit tools, job aids, and training materials for the credentialing department.
• Track and report key performance metrics (e.g., file completion rates, turnaround times, expirables compliance, payor enrollment delays).
• Maintain complete, organized documentation required for internal audits, NCQA surveys, and delegated audits.

• Cross-Fun…