Delegated Credentialing Manager

Job Description

Job Description

About the Role:

The Delegated Credentialing Manager plays a critical role in overseeing and managing the credentialing process for healthcare providers within delegated networks. This position ensures compliance with regulatory standards and organizational policies by coordinating credentialing activities, audits, and reporting. The manager leads a team responsible for verifying provider qualifications, maintaining accurate records, and facilitating timely re-credentialing to support network integrity and patient safety. They act as a liaison between internal departments, external providers, and regulatory bodies to resolve credentialing issues and implement process improvements. Ultimately, this role ensures that all delegated credentialing functions are executed efficiently, accurately, and in alignment with industry best practices and accreditation requirements.

Minimum Qualifications:

• Bachelor’s degree in Healthcare Administration, Business, or a related field.
• Minimum of 5 years of experience in healthcare credentialing or provider network management.
• Strong knowledge of NCQA, URAC, and other relevant credentialing standards and regulations.
• Proven experience managing delegated credentialing processes and teams.
• Excellent organizational, communication, and leadership skills.

Preferred Qualifications:

• Certified Provider Credentialing Specialist (CPCS) or equivalent certification.
• Experience working within managed care organizations or health plans.
• Familiarity with credentialing software and database management systems.
• Advanced knowledge of healthcare compliance and regulatory environments.
• Demonstrated ability to lead process improvement initiatives.

Responsibilities:

• Manage and oversee the delegated credentialing process, ensuring compliance with NCQA, URAC, and other regulatory standards.
• Coordinate and conduct audits of credentialing files and processes to maintain accuracy and completeness.
• Lead, train, and support the credentialing team to meet performance goals and maintain high-quality standards.
• Collaborate with internal departments, external providers, and delegated entities to resolve credentialing discrepancies and issues.
• Develop and implement policies and procedures to improve credentialing workflows and ensure timely provider enrollment and re-credentialing.
• Prepare and present credentialing reports and metrics to senior leadership and regulatory agencies as required.
• Maintain up-to-date knowledge of industry regulations, accreditation standards, and best practices related to credentialing.

Skills:

The Delegated Credentialing Manager utilizes strong organizational and leadership skills daily to coordinate complex credentialing workflows and manage team performance effectively. Analytical skills are essential for conducting audits, identifying discrepancies, and ensuring compliance with regulatory standards. Communication skills are critical for liaising with providers, internal stakeholders, and regulatory bodies to resolve issues and convey credentialing requirements clearly. Proficiency with credentialing software and data management tools supports accurate record-keeping and reporting. Additionally, problem-solving and process improvement skills enable the manager to streamline operations and maintain high standards of quality and efficiency in credentialing activities.