Senior Manager, Credentialing and Delegation Oversight

Summary

Join Inovalon as a Senior Manager, Credentialing and Delegation Oversight and oversee both credentialing and delegation oversight functions. Ensure compliance with regulations and standards, supervise credentialing staff, and continuously improve processes. Manage the credentialing of healthcare providers, including verification and tracking of credentials. Oversee vendor audits, manage complaints, and ensure compliance with delegation agreements. Prepare reports for senior leadership and address complex issues. Maintain compliance with organizational policies and ensure alignment with organizational goals. This role requires significant experience in healthcare credentialing and delegation oversight, strong leadership skills, and in-depth knowledge of relevant regulations.

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
• Ability to work in a fast-paced environment with time sensitive deadlines
• High school diploma and relevant work experience

Responsibilities

• 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
• 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

Preferred Qualifications

Certified Provider Credentialing Specialist (CPCS) with NAMSS

Benefits

• Competitive Salary and Benefits Package
• Performance-based incentives
• Base Compensation Range $80,000 — $95,000 USD