About this position
Summary:
The Senior Manager, Enrollment & Credentialing leads all operational activities related to provider enrollment, credentialing, delegated credentialing, and provider roster management. This role ensures compliance with NCQA standards, payor delegation requirements, and regulatory guidelines while driving operational excellence and audit readiness across the credentialing lifecycle
Essential Duties and Responsibilities:
•Lead and develop the Enrollment & Credentialing team, ensuring timely, accurate, and compliant completion of all credentialing and enrollment activities.
•Establish performance metrics, SLAs, and standardized workflows for credentialing, enrollment, and roster management.
•Partner cross‑functionally with Network, Clinical, Revenue Cycle, Compliance, and IT teams.
•Oversee enterprise provider roster management, ensuring data accuracy, completeness, and timely updates.
•Implement and maintain roster reconciliation processes with payors.
•Lead governance and quality control for provider demographic and credentialing data.
•Manage delegated credentialing programs, including delegation agreements and reporting.
•Oversee Primary Source Verification (PSV) activities.
•Maintain compliant credentialing files and committee documentation.
•Direct payer enrollment functions including initial enrollment, revalidations, and updates.
•Reduce time-to-enrollment and minimize enrollment‑related claim denials.
•Serve as escalation point for complex payor enrollment issues.
•Manage credentialing vendors, CVOs, and software systems.
•Monitor vendor SLA performance and cost.
•Oversee system optimization and reporting tools.
•Lead NCQA accreditation and reaccreditation activities.
•Conduct gap assessments, training, and documentation reviews.
•Maintain internal audits for ongoing NCQA compliance.
•Serve as primary contact for payer pre-delegation and recurring audits.
•Coordinate audit documentation and corrective action plans.
•Maintain year-round audit readiness.
•Develop dashboards and compliance reports.
•Ensure adherence to regulatory and accreditation requirements.
Measurable Goals/Objectives:
•Achieve pass rates for all payor pre-delegation and recurring audits
•Achieve 90%+ score on NCQA Accreditation
•Achieve 95%+ accuracy on all file reviews and internal audits
Supervisory Responsibilities:
•Supervise a team of credentialing coordinators and specialists
Competencies: To perform the job successfully, an individual should demonstrate the following competencies:
•Strong understanding of NCQA and delegated credentialing
•Project management expertise
•Exceptional communication and relationship-building skills with both internal teams and external partners
•Ability to manage multiple priorities in a fast-paced environment
•Proficiency in Excel, PowerPoint, and analytics/reporting tools.
•Safety and Security - Uses equipment and materials properly.
•Attendance/Punctuality - Is consistently at work and on time.
•Knowledge of medical records work procedures.
•Knowledge of computer applications.
•Knowledge of medical terminology.
•Knowledge of legal and ethical consideration related to patient information.
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience:
7–10+ years of experience in credentialing, enrollment, or delegated credentialing. 3–5+ years leadership experience. Deep knowledge of NCQA standards and payor delegation requirements. Experience with payor audits and corrective actions. Proficiency with credentialing/enrollment systems. CPCS or CPMSM certification preferred. Experience with multi-state provider networks. Experience with workflow improvement and system enhancements. NCQA accreditation experience. Bachelor’s degree required; Master’s preferred.
Language Skills:
Ability to read and comprehend simple instructions, correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one situations to visitors, clients, and other employees of the organization.
Reasoning Ability:
Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.
Computer Skills:
MS Office Productivity Tools (Word, Excel, Outlook, PowerPoint)
Other Skills and Abilities:
High accuracy and extreme confidentiality a MUST. Detailed oriented and very organized. Ability to alphabetize and put information (materials, forms, etc.) into chronological order. Analyze medical records for completeness, schedule time and assignment effectively.
Physical Demands:
While performing the duties of this Job, the employee will have a combination of standing, sitting, bending and reaching. May work at a computer monitors for prolonged periods. The employee may lift and/or move up to 10 pounds.
Travel Requirements:
Travel required within the defined region up to 25%, with travel to headquarters up to twice a year possible.
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Salary Information