Credentialing Manager

Credentialing Manager

We’re looking for a leader with significant experience in healthcare credentialing compliance and process improvement. The Credentialing Manager is a critical role responsible for ensuring the organization's audit readiness and adherence to all regulatory and contractual requirements related to delegated credentialing. This individual will develop and own the quantifiable Compliance Scorecard manage payer audit cycles and lead high-impact initiatives to improve overall RCM efficiency and compliance for our platform.

Key Responsibilities

Audit & NCQA Compliance Ownership

• Delegation Audit Management: Serve as the subject matter expert and primary liaison for all insurance payer audits related to delegated credentialing agreements

• NCQA Standard Implementation: Implement and maintain NCQA standards and requirements across all credentialing policies and procedures to uphold accreditation readiness and quality assurance

• Compliance Scorecard & KPIs: Design implement and maintain the Compliance Scorecard and KPIs for credentialing and RCM demonstrating measurable improvement year-over-year

• Audit Preparedness: Ensure the organization is prepared for annual audits by developing a playbook and ensuring improvements based on any previous Corrective Action Plans (CAPs)

• Policy & Regulatory Monitoring: Work with Legal and Compliance to monitor changes in payer state and federal laws and rapidly update internal policies and Standard Operating Procedures (SOPs) accordingly

RCM Integrity and Process Improvement

• RCM Compliance Leadership: Lead compliance efforts within the RCM division focusing on the regulatory intersections between credentialing enrollment and claims processing

• Efficiency & Scalability: Identify and eliminate bottlenecks in the Credentialing and RCM workflows specifically targeting root causes of claim denials and credentialing delays to improve the Clean Claim Rate

Leadership & Cross-Functional Management

• Partner Oversight: Oversee the performance of any Credentials Verification Organization (CVO) partners and internal support partners to ensure their work meets NCQA and organizational quality standards

• Compliance Training: Ensure annual required trainings are completed for all RCM and Credentialing staff

• Committee Support: Facilitate and support the Credentialing Committee ensuring committee decisions are documented and adhered to in alignment with all policies and procedures

• Execution-Oriented Mindset: Act as a hands-on individual contributor when necessary diving into operational details troubleshooting issues and executing complex tasks to drive continuous improvement

What you bring

• Robust Credentialing Leadership: 6+ years of progressive experience in healthcare credentialing with a significant portion dedicated to managing delegated functions

• Delegated Credentialing Expertise: Deep demonstrated experience supporting and managing delegated credentialing agreements including familiarity with pre- and post-delegation audit requirements and payer submission processes

• NCQA Proficiency: Deep understanding and practical experience with NCQA standards and their application to both credentialing files and quality committee structure

• RCM Compliance & Behavioral Health Knowledge: Strong working knowledge of the Revenue Cycle Management process and the regulatory nuances specific to mental/behavioral health services (e.g. medical necessity documentation)

• Compliance Measurement: Proven experience establishing monitoring and reporting compliance KPIs and scorecards

• Project Management & Organization: Exceptional organizational and project management skills with a demonstrated ability to manage complex detailed and timeline-driven compliance projects independently

Required Qualifications

• Proven ability to interpret complex regulatory language (NCQA CMS etc.) and translate it into operational workflows

• 6+ years of progressive experience in healthcare credentialing with a focus on managing delegated functions

Preferred Qualifications

• Professional Certification: CPCS (Certified Provider Credentialing Specialist) or CHPC (Certified in Healthcare Privacy and Compliance)

• Experience in the Mental Health/Behavioral Health sector understanding specific parity requirements and documentation rules

• Experience working in a high-growth healthcare technology or start-up environment

Benefits:

• We’re a remote-first company

• Health insurance plans through Aetna (medical and dental) and MetLife (vision) including FSA and HSA plans

• 401K plan (ADP)

• Monthly therapy and wellness stipends

• Monthly co-working space membership stipend

• Monthly work-from-home stipend

• Financial wellness benefits through Northstar

• Pet discount program through United Pet Care

• Financial perks and rewards through BenefitHub

• EAP access through Aetna

• One-time home office stipend to set up your home office

• Comprehensive parental leave plans

• 12 paid holidays and 1 Alma Give Back Day

• Flexible PTO

Salary Band: $110000 - $130000

All Alma jobs are listed on our careers page. We do not use outside applications or automated text messaging in our recruiting process. We will not ask for any sensitive financial or identification information throughout the recruiting process. Any communication during the recruitment process including interview requests or job offers will come directly from a recruiting team member with a helloalma.com email address.