Manager, Provider Credentialing Operations Implementation

Job Summary:

The Manager, Provider Credentialing Operations Implementation is responsible for managing provider credentialing processes for new market implementations within a managed care organization. This position will ensure that all providers meet necessary standards, comply with regulatory requirements, and are efficiently onboarded and maintained within the system.

Essential Functions:

• Manage and lead a team of credentialing specialists to ensure the timely and accurate credentialing of healthcare providers
• Design and implement credentialing policies, workflows, and procedures that ensure compliance with applicable regulatory standards (e.g., NCQA, URAC) and contractual obligations
• Lead projects related to the initial setup and ongoing maintenance of provider credentialing operations and ensure all systems and processes are optimized for efficiency and compliance
• Monitor the credentialing process to ensure all regulatory and internal compliance requirements are met
• Work closely with other departments to ensure smooth implementation and execution of credentialing processes and serve as the key point of contact for provider credentialing inquiries and issues
• Develop and deliver training programs for team members and internal stakeholders on provider credentialing policies, systems, and best practices
• Prepare and present regular reports on credentialing status, performance metrics, and any issues related to provider onboarding and credentialing
• Continuously evaluate the provider credentialing process and recommend improvements to increase operational efficiency, reduce processing time, and enhance provider satisfaction
• Perform any other job duties as requested

Education and Experience:

• Bachelor’s degree in Healthcare Administration, Business Administration, a related field or equivalent years of relevant work experience
• Five (5) years of experience in managing credentialing operations is required
• Previous leadership experience is required
• Experience with credentialing software systems and the use of electronic tools for managing provider data
• Experience with provider data application within Cognizant Facets system

Competencies, Knowledge and Skills:

• In-depth knowledge of provider credentialing regulations, policies, and procedures within managed care organizations
• Skilled in process improvement and project management
• Ability to lead, mentor, and motivate a team to achieve goals and meet deadlines. Strong decision-making and problem-solving capabilities
• In-depth knowledge of credentialing processes, regulations, and industry standards, including NCQA, URAC, CMS guidelines, and state-specific requirements
• High level of accuracy and attention to detail, ensuring all provider information is thoroughly vetted and compliant
• Strong verbal and written communication skills
• Ability to present complex information in a clear and concise manner to both internal stakeholders and external partners
• Proficient in managing multiple projects simultaneously, balancing priorities, and maintaining timelines
• Familiarity with credentialing software systems (e.g., Cactus, CAQH, Verity, or similar platforms), along with MS Office Suite (Excel, Word, PowerPoint)
• Ability to identify issues and implement effective solutions, balancing operational efficiency with regulatory compliance
• Strong focus on customer service, both for internal and external stakeholders
• Ability to analyze and interpret data, track performance metrics, and make data-driven recommendations for improvement

Licensure and Certification:

• None

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time
• Occasional travel may be required

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Create an Inclusive Environment

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an inclusive environment that welcomes and supports individuals of all backgrounds.