Senior Manager, Credentialing and Delegation Oversight

Overview:  The Senior Manager, Credentialing and Delegation Oversight is responsible for overseeing and managing both the credentialing and delegation oversight functions within the organization. This role ensures compliance with federal, state, and organizational regulations, accreditation standards, and internal policies related to credentialing healthcare providers and the oversight of third-party vendor performance. The Senior Manager will supervise credentialing staff, ensure continuous improvement of credentialing processes, and ensure all delegated activities align with regulatory and client commitments.

Key Responsibilities:

Credentialing:

• Supervise and lead a team of credentialing specialists, coordinators, and administrative staff, setting clear goals and expectations, providing training, and conducting performance reviews.
• Ensure that all credentialing activities are compliant with federal, state, and organizational regulations, including NCQA, HIPAA, and other relevant standards.
• Oversee the credentialing process for healthcare providers, including verification of credentials (e.g., licenses, certifications, education, and malpractice claims).
• Manage initial credentialing for new providers and oversee recredentialing to ensure providers maintain valid credentials and meet performance and quality requirements.
• Ensure timely tracking of expiring credentials to prevent lapses in provider eligibility.
• Conduct internal audits to verify the completeness and accuracy of credentialing files and ensure compliance with regulatory standards.
• Develop, review, and update Standard Operating Procedures (SOPs) to align with regulatory changes and best practices.
• Track key performance indicators (KPIs) related to credentialing, such as turnaround times, accuracy, and provider satisfaction.
• Prepare and present reports to senior leadership on credentialing status, bottlenecks, compliance risks, and performance metrics.
• Address complex or escalated credentialing issues, resolving conflicts related to credentialing discrepancies or delays.
• Ensure all collaborative relationships between providers and collaborating physicians align with state regulations. Continuously assess and improve credentialing processes to increase efficiency, reduce errors, and enhance provider satisfaction.

Delegation Oversight and Auditing:

• Supervise daily vendor audit operations, ensuring that all audits are completed within the designated time frames and in compliance with established guidelines. This includes monitoring progress, identifying potential delays, and taking proactive steps to keep audits on schedule, ensuring that all tasks are performed thoroughly and efficiently. Ensure that third-party vendors meet the required federal, state, and NCQA standards as outlined in delegation agreements.
• Manage the complaints process to ensure all issues are resolved within the agreed-upon client and departmental service level agreements (SLAs).
• Regularly review daily complaint reports to identify any missed opportunities for improvement and take corrective action as needed to enhance service delivery.
• Evaluate performance against client commitments and internal performance standards, ensuring compliance with the organization's Delegation Policy.
• Prepare and manage corrective action plans when deficiencies are identified with third-party vendors.
• Work closely with product departments to ensure that processes, policies, and workflows support delegated activities, with appropriate checks and balances in place.

• Maintain compliance with the organization's policies, procedures, and mission statement, ensuring that credentialing and delegation oversight functions align with organizational goals.
• Adhere to confidentiality and HIPAA requirements in all aspects of credentialing, delegation oversight, and other related activities.

• Participate in regular reviews of delegation processes and implement best practices to drive continuous improvement and quality assurance.
• Identify opportunities for professional development and training to ensure that staff members remain up-to-date with the latest credentialing practices, regulatory requirements, and delegation policies.

Job Requirements:

• A minimum of 7 years of experience in healthcare credentialing and delegation oversight, including at least 2 years in a managerial role.
• Knowledge and understanding of standard credentialing and re-credentialing processes and best practices.
• Must have the ability to maintain professional relationships with providers and outside organizations
• In-depth knowledge of federal, state, and industry regulations related to credentialing (e.g., HIPAA, NCQA, Affordable Care Act).
• Strong leadership skills, with the ability to mentor and develop a team.
• Experience in working with third-party vendors and overseeing their performance.
• Excellent communication, problem-solving, and conflict-resolution skills.
• Strong organizational skills with the ability to manage multiple projects and priorities simultaneously. Must possess a strong proficiency with Microsoft Office Suite (Word/Excel/Outlook/PowerPoint).
• Strong knowledge of federal, state and NCQA Credentialing guidelines.
• Excellent verbal, written and interpersonal communication skills; and
• Ability to work in a fast-paced environment with time sensitive deadlines.

Education:

• High school diploma and relevant work experience.
• Certified Provider Credentialing Specialist (CPCS) with NAMSS preferred

Physical Demands and Work Environment:

• Sedentary work (i.e. sitting for long periods of time);
• Exerting up to 10 pounds of force occasionally and/or negligible amount of force;
• Frequently or constantly to lift, carry push, pull or otherwise move objects and repetitive motions;
• Subject to inside environmental conditions; and
• Travel for this position will include less than 5% locally usually for training purposes.

Studies have shown that women and people of color are less likely to apply for jobs unless they believe they meet every one of the qualifications listed in a job description. If you don’t meet every qualification listed but are excited about our mission and the work described, we encourage you to apply regardless.  ComplexCare Solutions is most interested in finding the best candidate for the job and you may be just the right person for this or other roles.

By embracing diversity, equity and inclusion we enhance our work environment and drive business success. ComplexCare Solutions strives to reflect the diversity of the communities where we operate and of our clients and everyone whom we serve. We endeavor to create a culture of inclusion in which our associates feel empowered to bring their full, authentic selves to work and pursue their professional goals in an equitable setting. We understand that by fostering this type of culture, and welcoming different perspectives, we generate innovation and growth.

ComplexCare Solutions is proud to be an equal opportunity workplace and is an affirmative action employer. We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity or Veteran status. We also consider qualified applicants regardless of criminal histories, consistent with legal requirement.

The Company maintains a drug free work environment for all of its associates, which includes employees, contractors and vendors. It is unlawful for associates to manufacture, sell, distribute, dispense, possess or use any controlled substance or marijuana in the workplace and doing so will result in disciplinary action, up to and including termination of employment or the contracted relationship.