Credentialing Manager

Credentialing Manager

The Credentialing Manager is responsible for overseeing all aspects of payer enrollment, recredentialing, and ongoing maintenance of provider participation in insurance networks. This role ensures compliance with regulatory requirements and payer-specific standards, while streamlining credentialing processes to support rapid onboarding of new providers and locations across the organization.

Wage will be determined based on knowledge, skills, and experience. Remote position.

Essential Responsibilities:

• Credentialing & Enrollment Oversight
  • Manage and execute the end-to-end credentialing life cycle (initial credentialing, recredentialing, and expiration tracking)
  • Oversee payer enrollment applications, PECOS updates, CAQH maintenance, NPPES records, and delegated agreements
  • Monitor and ensure compliance with NCQA, CMS and commercial payer standards
  • Maintain an accurate credentialing database
• Team & Process Management
  • Lead, supervise, and support team of Provider Enrollment Specialists, ensuring timely submission and follow-up of applications
  • Establish, document, and refine credentialing workflows, SOPs, and KPIs
• Payer & Regulatory Communication
  • Act as primary liaison with insurance plans to resolve enrollment delays or issues
  • Stay current with payer policy updates and state/federal regulations
  • Support audits related to credentialing files
• Reporting & Metrics
  • Provide weekly and monthly updates on credentialing status and turnaround times
  • Track and report on pending expirations to avoid lapses
  • Prepare credentialing rosters and enrollment summaries
• Perform other duties as assigned

Core Leadership Expectations:

• Strategic Development:
  • Be a champion of the company's overall culture and commitment to patient care.
  • Align strategic goals and resources to maximize profitability.
  • Collaborate across the organization to identify needs and develop scalable solutions.
  • Work on integration and post-acquisition teams as needed.
• Performance Management:
  • Drive operational excellence to achieve the organization's financial goals.
  • Maintain compliance with the organization's policies and applicable regulatory guidelines.
• Staff Development:
  • Build and lead creative, collaborative teams; develop people; and link performance to overall business objectives.
  • Guide and evaluate the work of other employees, including peers, to ensure a healthy working environment.
  • Proactively recruit, hire, train, motivate and retain current and future leaders.

Education, Experience, and Certification:

• Bachelor's degree or equivalent experience required
• 3-5 years of credentialing experience; 2+ years in a supervisory role
• Experience in optometry/ophthalmology or outpatient healthcare preferred
• Experience in delegated credentialing and/or managed care contracting preferred
• CPCS or CPMSM certification preferred

Competencies:

• Strategic Relationship Management
• Advanced Communication Skills
• Influence & Negotiation Skills
• Cross-Functional Collaboration
• Process Improvement & Problem Solving
• Project & Time Management
• Proficiency in Microsoft Office
• Strong knowledge of CPT, ICD-10, and HCPCS codes relevant to optometry/ophthalmology
• Knowledge of insurance guidelines relevant to optometry/ophthalmology
• Attention to detail
• Professional Integrity

Physical Demands and Work Environment (per ADA guidelines):

• Physical Demands:
  • Sedentary work requiring prolonged periods of sitting at a computer workstation
  • Regular use of hands and fingers for keyboarding and other standard office equipment
  • Ability to communicate effectively through verbal and written means
  • Ability to hear and understand spoken information in-person and via electronic means
  • Visual acuity to ensure the accuracy of work performed on screens and in documents
  • Ability to maintain focus and attention to detail for extended…