Credentialing Manager 526 views

American Specialty Health, Inc. is seeking an experienced manager to oversee our practitioner credentialing administration department. The primary function of this position is to oversee Practitioner Contract Administration Staff and for the department to meet all performance standards.   Also, maintains compliance to NCQA and URAC standards and business objectives as it relates to Practitioner Contract Administration and Services departments.

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  • Manages the practitioner credentialing function for company network of practitioners, with duties including ongoing compliance, and monthly monitoring of performance.
  • Ensuring the appropriate processes are in place to monitor and maintain systematic, timely credentialing and re-credentialing of network practitioners and providers.
  • Develop and implementing standards to ensure the accuracy of practitioner credentialing.
  • Coordinating the analysis of data relevant to the credentialing process.
  • Ensure the appropriate information is prepared for administrative review and credentialing committee relevant to credentialing criteria /data.
  • Manage projects related to the credentialing program within the department and by collaborating with other departments.
  • Responsible to help maintain corporate objectives through the credentialing and maintenance of the company network of practitioners
  • Assist in preparation for state and federal audits, responding to client auditor’s inquiries and preparing responses to auditor findings
  • Training staff with the credentialing function and acting as a resource for staff including training staff on NCQA and URAC guidelines.
  • Monitoring and evaluating day to day activities for the credentialing staff.
  • Responding to non-routine and difficult credentialing issues when the staff requires assistance.
  • Supervises and trains the practitioner credentialing examiners, primary verification examiners, and front end examiners, supervisors and team leads.
  • Conduct regular meetings with staff and provide back-up support for the credentialing function when the staff are out of the office or unavailable.
  • Collaborates with all levels of management across functional departments to achieve departmental goals and objectives.
  • Interfaces effectively with various members of management and staff to improve various processes by way of discussion, analysis, internal audit, recommendation and implementation in order to assure quality.
  • Creates and revises credentialing policies, procedures, and workflows to ensure compliance with all regulatory  accreditation, health plan delegation and contractual credentialing requirements. Performs other duties and responsibilities as assigned.
  • Ability to travel both in and out of state 5% to 10% of the time.


  • Bachelor Degree in Business, Health Administration, Public Administration or equivalent experience.  If equivalent experience, high school diploma required.
  • 5 years of progressive experience, 2 of which have been in a supervisory capacity or management level experience in managed care, medical staff services, health services or government assistance programs; or an equivalent combination of education and experience which would provide the required knowledge, skills and abilities.
  • Certified Provider Credentialing Specialist (CPCS) preferred.
  • Familiarity with specialty health plans (HMO, PPO, POS and related plans).
  • Proficient with Microsoft Office, including Access, Word, Excel and Power Point.
  • Ability to plan, assign, supervise and evaluate the work of others, and to monitor goals, objectives, deadlines and priorities.
  • Ability to manage multiple projects effectively while facilitating group success.
  • Ability to analyze, interpret and synthesize a wide range of information, including legal and contract language, policies, standards and guidelines.
  • Ability to analyze complex data related to credentialing.
  • Knowledge of Credentialing/re-credentialing, delegation oversight, NCQA, URAC and managed care experience (Medicaid, Medicare, and Commercial) required.
  • Knowledge of the performance improvement process.
  • The ability to think strategically, implement tactically and the ability to position the organization for the future.
  • Preferred knowledge of CAQH.
  • Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.
  • Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.
  • Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.
  • Ability to effectively organize, prioritize, multi-task and manage time.
  • Demonstrated accuracy and productivity in a changing environment with constant interruptions.
  • Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.
  • Ability to exercise strict confidentiality in all matters.
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