Founding Credentialing Manager/Director

Job Title: Director/Manager of Health Plan Credentialing

Location: Hybrid, with periodic on‑site presence required
Department: Operations

Background

We are a mission‑driven health organization dedicated to making high‑quality healthcare accessible, affordable, and equitable. Our model blends a virtual‑first care approach with integrated in‑person services, offering members low‑cost access to providers and essential medications. We operate in multiple states and are expanding rapidly.

If you are passionate about improving care quality, reducing healthcare costs, and designing better health and financial outcomes for members-and you thrive in a dynamic, growth‑stage environment-this role offers a meaningful opportunity to make an impact.

Job Summary

The Director/Manager of Health Plan Credentialing is responsible for overseeing all provider and practitioner credentialing and recredentialing activities. This includes ensuring regulatory compliance, managing delegated credentialing relationships, and leading the Credentialing Committee.

This role requires close collaboration with internal departments and external partners to maintain a high‑quality, compliant provider network. The Manager will direct day‑to‑day credentialing operations, supervise credentialing staff, ensure data accuracy, and champion process improvements across the credentialing function.

Key Responsibilities

• Oversee credentialing and recredentialing activities in accordance with NCQA, CMS, and state regulations, ensuring deadlines are met.
• Manage professional licensing activities and integrate data with HR systems.
• Oversee delegated credentialing programs, including performance monitoring and audit preparation.
• Conduct provider outreach to obtain documentation and resolve discrepancies.
• Lead the Credentialing Committee, including agenda preparation, minutes, documentation review, and coordination with clinical leadership.
• Maintain relationships with external credentialing verification partners.
• Audit provider rosters, validate CAQH data, and ensure accurate provider records.
• Supervise, train, and evaluate credentialing team members.
• Collaborate with contracting, provider relations, quality, and data teams to support onboarding and maintain network integrity.
• Develop, update, and maintain credentialing policies and procedures.
• Prepare and present reporting on credentialing metrics, audit results, and compliance performance.
• Respond to accreditation audits, internal reviews, and regulatory inquiries.
• Lead process improvement initiatives to streamline workflows and enhance provider experience.
• Use credentialing platforms and reporting tools to optimize operational efficiency.

Qualifications

• Bachelor's degree in healthcare administration, business, or related field preferred (or equivalent experience).
• CPCS or CPMSM certification ideal.
• Minimum 5 years of experience in health plan credentialing, including 2+ years in a supervisory role.
• Experience with delegation oversight, Credentialing Committee operations, and NCQA standards.
• Familiarity with CAQH and credentialing software platforms.
• Strong analytical, organizational, and communication skills.

Skills & Competencies

• Deep understanding of NCQA, CMS, and state regulatory requirements.
• Ability to interpret and apply accreditation standards within credentialing workflows.
• Experience with primary source verification, provider enrollment, and audit preparation.
• Ability to develop and refine credentialing policies and procedures.
• Experience preparing corrective action plans and monitoring performance metrics.
• Knowledge of accreditation standards and payer requirements.
• Expertise in designing credentialing dashboards and databases.
• Strong leadership skills with experience mentoring and managing staff.
• Ability to build a collaborative, accountable team culture.
• Skilled at presenting cases and data to committees and leadership groups.
• Ability to identify inefficiencies and implement optimized workflows using KPIs.
• Strong problem‑solving skills to resolve provider documentation issues and discrepancies.

Work Environment

• Hybrid role with periodic on‑site presence required.
• Must maintain a quiet, secure, and private remote workspace to ensure HIPAA compliance.
• May require occasional travel.