credentialing manager

RK Med Pro

Job SummaryThe Credentialing Manager will oversee offshore credentialing operations in Pakistan, ensuring U.S. provider credentialing and recredentialing activities comply with NCQA, CMS, and payer requirements, while managing team performance and audit readiness.Key Responsibilities<ul><li>Lead end-to-end provider credentialing, recredentialing, and Primary Source Verification (PSV)</li><li>Ensure compliance with NCQA standards and delegated credentialing guidelines</li><li>Manage CAQH reviews, licenses, DEA, board certifications, sanctions, and work history checks</li><li>Supervise, train, and evaluate offshore credentialing staff</li><li>Coordinate with U.S. clients, payers, and providers across time zones</li><li>Maintain audit-ready documentation and credentialing reports</li></ul>Required Qualifications<ul><li>Bachelor&rsquo;s degree or equivalent experience</li><li>4&ndash;6+ years of U.S. healthcare credentialing experience</li><li>Strong knowledge of NCQA, CMS, Medicare/Medicaid, and commercial payers</li><li>Excellent English communication and team-management skills</li></ul>Job Type: Full-timePay: Rs100,000.00 - Rs300,000.00 per monthWork Location: In person

Credentialing Manager

Hillcrest HealthCare System

<div>Overview:

Join our team as a Regional Manager of Medical Staff Services in Tulsa, OK.<div> 
Why Join Us?</div><div> 
Thrive in a People-First Environment and Make Healthcare Better</div><div><ul><li>
Thrive: We empower our team with career growth opportunities, tuition assistance, and resources that support your wellness, education, and financial well-being.</li><li>
People-First: We prioritize your well-being with paid time off, comprehensive health benefits, and a supportive, inclusive culture where you are valued and cared for.</li><li>
Make Healthcare Better: We use advanced technology to support our team and enhance patient care.</li></ul></div><div>
 Get to Know Your Team:</div><div><ul><li>
Hillcrest Medical Center is a 656-bed hospital that includes The Alexander Burn Center, The Peggy V. Helmerich Women&rsquo;s Health Center, Kaiser Rehabilitation Center, the latest technology for the treatment of cancer, and the Oklahoma Heart Institute.
</li></ul></div>Responsibilities:

The Regional Manager of the Medical Staff Services will oversee the day-to-day operations of multiple facilities within assigned region and staff who assist with the credentialing activities for physicians and other independent practitioners at Hillcrest Health Systems (HHS). Will serve as a liaison between facility and market leadership, medical staff elected leaders and credentialing medical office staff. Subject matter expert in market and regional specifics related to medical staff governance including clinical services offered, medical staff bylaws, rules &amp; regulations, and related policies. Ensure regulatory survey preparedness, actively participating in regulatory related activities. Responsible for the coordination of all operational aspects of the assigned region, including organizing and conducting programs and establishing procedures for all medical staff functions. Assign workflow and oversee the tracking of medical professionals to ensure proper training, certifications, and experience, and licensures meet medical staff bylaws. Assign workflow and manage the review process of all physician files for completeness and &ldquo;red flags&rdquo; and acts to support the medical staff providers and staff in the credentialing process. Works closely with all HHS facilities and the provider groups to assist and oversee the facilitating the credentialing of the physicians and other healthcare providers. Works cooperatively with outside review organizations, hospital personnel, nursing services, ancillary services, and physicians in a friendly, courteous, and efficient manner to educate all parties regarding credentialing and the Medical Staff organization requirements as outlined in the Medical Staff Bylaws. Resolves complex questions regarding credentialing or provider database maintenance and best practices. Monitoring and tracking trends at each facility assigned. Manages and contributes to the development and processes and procedures. Overseeing recruitment, implementing regulations, monitoring budget, and staying updated on medical trends to ensure efficient operations and high- quality patient care. Assists in department staffing issues, such as annual evaluations, disciplinary actions, etc.
Qualifications:

Job Requirements:<ul><li>
High School Diploma or equivalent</li><li>
Associate's degree</li><li>
3 years of experience in medical staff services and credentialing</li><li>
3 years in a medical staff management role</li><li>
CPCS or CPMSM completed or in progress to complete</li></ul>
Preferred Job Requirements:<ul><li>
Bachelor's Degree.</li></ul></div>

Regional Medical Staff Manager

<div>Summary:

Lead the creation and ongoing management of PSW&rsquo;s Credentialing Department, ensuring compliance with NCQA, CMS, and payer requirements. Serve as the primary delegated entity for PSW customers, including health plans (payers), independent physician associations/groups (IPAs) and clinically integrated network (CINs). Oversee credentialing operations, contracting integration, and provider network alignment to support strategic growth and value-based care initiatives. In addition, this role will lead the strategic planning and implementation of PSW&rsquo;s Credentials Verification Organization (CVO) to support delegated credentialing for health plans and provider networks, ensuring compliance with NCQA and other accreditation standards.
<div>
Essential Functions: 
Department Establishment &amp; Leadership: 
<ul><li>Design and implement PSW&rsquo;s Credentialing Department, including policies, workflows, and staffing.</li><li>Develop and maintain the Credentialing Delegation Manual and ensure annual updates.</li><li>Collaborates to develop communications, presentations, proposals and other work product as needed.</li><li>Works closely with compliance to ensure credentialing requirements are met, including regular audits</li><li>Lead organizational initiatives within areas of oversight to ensure efficiency and maintain compliance with the policies and standards, government laws and regulations.</li></ul>
Delegated Entity Oversight: 
<ul><li>Ensure compliance with NCQA, CMS, and payer standards through audits and performance monitoring.</li><li>Primary point of contact for all auditing, reporting, performance improvement and/or other follow-up concerning Credentialing System Controls, including oversight/compliance of any sub-delegations.</li><li>Serve as primary liaison for health plans and CINs regarding credentialing delegation agreements.</li></ul>
Contracting &amp; Provider Operations Integration: 
<ul><li>Collaborate with contracting, network management, provider engagement and operations teams to align credentialing processes with network development and payer agreements.</li><li>Support onboarding and contracting workflows to ensure timely provider participation.</li></ul>
CVO Development &amp; Accreditation: 
<ul><li>Design and implement PSW&rsquo;s CVO infrastructure, including technology, workflows, and staffing models.</li><li>Develop policies and procedures to meet NCQA, URAC, and CMS standards for credentialing and primary source verification.</li><li>Lead readiness activities for NCQA accreditation and maintain compliance post-certification.</li><li>Evaluate existing, and/or select credentialing technology platforms to support CVO operations.</li><li>Establish service-level agreements (SLAs) for delegated credentialing services provided to payers, IPAs &amp; CINs.</li></ul>
Governance &amp; Compliance: 
<ul><li>Lead Credentialing Committee meetings with the Medical Director.</li><li>Oversee sub-delegation arrangements and ensure compliance with all regulatory requirements.</li></ul>
Performance Management: 
<ul><li>Provides critical thinking, developing insights from data reports and assists stakeholders with the translation of information to knowledge and useful action plans.</li><li>Plays a critical role in performance management by guiding actionable initiatives from data; measuring progress and outcomes and helping implement interventions where applicable</li><li>Develop KPIs for credentialing operations and delegated functions.</li><li>Drive continuous improvement initiatives using data analytics and stakeholder feedback to increase efficiency and outcomes.</li></ul>
Team Management: 
<ul><li>Hire, train, and manage credentialing staff.</li><li>Develop departmental budget and monitor financial performance.</li><li>Manages all credentialing and re-credentialing activities according to P&amp;Ps and in compliance with NCQA.</li><li>Leads credentialing committee meetings in conjunction with the medical director</li><li>Oversees required monthly ongoing monitoring activities, ensuring compliance with all NCQA, CMS, and health plan requirements.</li><li>Monitor performance, develop, and implement solutions to address process and gaps across delegated operations.</li><li>Ensures staff compliance with PSW policies and procedures with special emphasis on HIPAA requirements</li><li>Builds and leverages cross-functional collaborative relationships to facilitate a team-work oriented atmosphere and achieve company goals.</li></ul>
Strategic Growth: 
<ul><li>Build scalable processes to expand CVO services to external clients.</li><li>Develop pricing models and operational metrics for CVO services.</li></ul></div>
<div>
Knowledge/Skills/Abilities: 
<ul><li>Excellent computer proficiency (MS Office &ndash; Word, Excel, Outlook) including being able to effectively maintain written and computer records in accordance with regulatory agencies.</li><li>Set a positive example by displaying a pleasant and approachable demeanor at all times.</li><li>Proactive team player, strong follow-through, quick decision-making abilities and ability to problem solve.</li><li>Interpersonal skills, with the ability to build strong relationships at all levels.</li><li>Strong verbal and written communication skills with customers, supervisors and co-workers.</li><li>Strong organizational, time management and prioritization skills.</li><li>Self-starter. Ability to set priorities and keep to projected schedules.</li></ul></div><div>
<div>
Required Education and/or Work Experience: 
<ul><li>Experience in building or managing a CVO or similar credentialing entity.</li><li>Knowledge of NCQA accreditation standards and delegated credentialing requirements.</li><li>Proven ability to lead large-scale operational transformation projects.</li></ul></div>
<div>
Preferred Education and/or Work Experience: 
<ul><li>Bachelor&rsquo;s degree in business, Health Administration, or related field (Master&rsquo;s preferred).</li><li>7+ years in credentialing with health plan and provider network experience, i.e.) facility, ancillary, practitioner, including delegated credentialing.</li><li>Proven experience in contracting integration, provider operations, and team leadership.</li><li>Strong knowledge of NCQA standards and delegated credentialing requirements. Health plan payer knowledge and changes within the Washington State healthcare landscape</li><li>CIN experience with a provider perspective and strong orientation to value-based care principles</li></ul></div>
<div>
Preferred but not required Certificates, Licenses and Registrations: 
<ul><li>CPCS or CPMSM certification.</li><li>Experience with credentialing technology platforms (e.g., MD-Staff, MedTrainer, Symplr, Verifiable).</li><li>Prior involvement in NCQA accreditation preparation.</li></ul></div> 

</div>
PSW does not typically hire new employees near the top of the salary range.
Benefits:
<ul><li>
401(k)</li><li>
401(k) matching</li><li>
Dental insurance</li><li>
Disability insurance</li><li>
Flexible Spending Account (FSA)</li><li>
Health Savings Account (HSA)</li><li>
Health insurance</li><li>
Life insurance</li><li>
Paid time off</li><li>
Tuition reimbursement</li><li>
Vision insurance</li></ul></div>

Director of Credentialing and Delegated Operations

Hiffey

Claims Med pioneers in Medical Billing for Healthcare providers in the United States. We are looking for fresh, energetic individuals who can not only add value to our firm, but also find endless opportunities in a growing firm. We are currently hiring individuals for our credentialing teams and looking for candidates(Preferably males) who are willing to learn and apply themselves in a short period of time- No Experience required.Job Description: Prepare, submit and track provider credentialing and re-credentialing applications. Maintain accurate provider information in CAQH, NPPES, PECOS and payer portals. Verify provider credentials Ensure compliance Coordinate site visits, address corrections and contract amendments as required by payers Maintain credentialing databases, spreadsheets and audit-ready files. Communicate regularly with providers, practice managers and insurance representatives regarding credentialing status Support facility credentialing and payer enrollment for new locations. Prepare reports on credentialing timelines, approvals, denials, and expirationsRequirements Night shift availability (7pm to 4am) Mondays to Fridays Graduation (required) English Proficiency is mustLocation Shaheed-e-Millat Rd, Karachi Paid training will be provided. Finalists will begin a 3-month probation period and will be re-evaluated before becoming permanent employees. Permanent employees enjoy several performance, and punctuality based bonuses, along with other perks.Please submit your resumes at hr@claimsmed.com and begin your journey of becoming an integral part of the Claims Med family.Job Type: Full-timePay: Rs40,000.00 - Rs45,000.00 per monthWork Location: In person

Credentialing Analyst

Speak Viral

The Credentialing Team Lead oversees the daily operations of the credentialing team to ensure accurate, efficient, and compliant processing of provider applications, verifications, and re-credentialing activities. This role serves as the primary liaison between the credentialing team, leadership, and other departments to maintain compliance with regulatory and payer requirements. The Team Lead is responsible for workflow coordination, staff training, quality assurance, and continuous process improvement within the credentialing function.Key Responsibilities:Leadership &amp; Team Oversight&middot; Supervise day-to-day credentialing activities to ensure timely and accurate completion of all provider files.&middot; Assign and monitor workloads to meet departmental goals and service level agreements (SLAs).&middot; Provide ongoing coaching, performance feedback, and training to credentialing specialists.&middot; Support new team members through onboarding and mentoring.Credentialing Operations&middot; Review and approve credentialing files prior to submission to payers or committees.&middot; Ensure compliance with NCQA, URAC, CMS, Joint Commission, and state/federal guidelines.&middot; Coordinate initial credentialing, re-credentialing, and primary source verification processes.&middot; Assist in the maintenance and auditing of credentialing databases and systems (e.g., CAQH, Cactus, Verity, or other platforms).&middot; Respond to escalated provider and payer inquiries in a timely and professional manner.Quality &amp; Compliance&middot; Monitor quality control measures to ensure data accuracy and regulatory compliance.&middot; Prepare reports and metrics on credentialing performance, turnaround times, and productivity.&middot; Support internal and external audits and ensure corrective actions are implemented as needed.&middot; Stay current with evolving industry regulations and best practices.Process Improvement &amp; Collaboration&middot; Identify workflow gaps and lead process improvement initiatives.&middot; Collaborate cross-functionally with provider enrollment, contracting, and human resources teams.&middot; Recommend system enhancements and contribute to policy and procedure updates.Qualifications:Education &amp; Experience&middot; Bachelor&rsquo;s degree preferred (Healthcare Administration, Business, or related field).&middot; Minimum 3&ndash;5 years of experience in provider credentialing or medical staff services.&middot; At least 1&ndash;2 years of experience in a leadership, senior, or team lead capacity preferred.Knowledge, Skills &amp; Abilities&middot; In-depth understanding of credentialing standards (NCQA, URAC, CMS, and state requirements).&middot; Strong organizational and multitasking abilities with keen attention to detail.&middot; Excellent written and verbal communication skills.&middot; Proficiency in credentialing software and Microsoft Office Suite.&middot; Ability to lead, motivate, and develop team members in a fast-paced environment.Job Type: Full-timePay: Rs70,000.00 - Rs110,000.00 per monthApplication Question(s):<ul><li>Will you be able to work in night shift(7pm to 4am)?</li><li>Will you be able to commute to Bahria Town Phase 7 Rawalpindi?</li></ul>Work Location: In person

Credentialing Team Lead

The Credentialing Executive is responsible for managing the provider enrollment and credentialing process with insurance companies, hospitals, and other healthcare organizations. This role ensures all providers are properly credentialed and enrolled to receive timely reimbursement for medical services, maintaining compliance with payer and regulatory requirements.Key Responsibilities:&middot; Prepare, review, and submit credentialing and re-credentialing applications for healthcare providers with commercial and government insurance payers (e.g., Medicare, Medicaid, BCBS, Aetna, UnitedHealthcare, Cigna, etc.).&middot; Maintain up-to-date records of providers in credentialing databases and online systems.&middot; Track the status of credentialing and enrollment applications, follow up with payers, and resolve any discrepancies or issues.&middot; Verify provider credentials, including licenses, board certifications, DEA, malpractice insurance, and other necessary documents.&middot; Coordinate with internal billing teams to ensure providers are properly linked and active with payers before billing.&middot; Update and maintain CAQH profiles, NPI registrations, and PECOS enrollments.&middot; Manage expirables (licenses, insurance, certifications) and notify providers of renewals.&middot; Ensure compliance with federal, state, and payer-specific regulations.&middot; Generate and maintain credentialing reports and dashboards.&middot; Communicate professionally with providers, practice managers, and insurance representatives.Required Qualifications:&middot; Bachelor&rsquo;s degree in Healthcare Administration, Business, or a related field (or equivalent work experience).&middot; 1&ndash;3 years of experience in medical credentialing, provider enrollment, or medical billing.&middot; Knowledge of CAQH, NPPES, PECOS, and payer portals.&middot; Strong understanding of commercial and government payer processes.&middot; Excellent communication and organizational skills.&middot; Proficiency in MS Office (Excel, Word, Outlook) and credentialing software.&middot; Ability to handle multiple tasks, prioritize, and meet deadlines.Preferred Qualifications:&middot; Experience with US-based healthcare systems or RCM/BPO companies.&middot; Certification in credentialing (e.g., CPCS, CPMSM) is a plus.&middot; Knowledge of medical billing and compliance regulations (HIPAA, CMS).Key Competencies:&middot; Attention to detail and accuracy&middot; Strong problem-solving and analytical skills&middot; Professional communication and interpersonal skills&middot; Time management and ability to work independently&middot; Team collaborationJob Type: Full-timePay: Rs30,000.00 - Rs50,000.00 per monthApplication Question(s):<ul><li>Will you be able to work night shift(7pm to 4am)?</li><li>Will you be able to commute to Bahria Town Phase 7 Rawalpindi?</li></ul>Work Location: In person

Credentialing Executive

claimcare

<ul><li>Ensure ongoing compliance with regulatory standards, such as those set by the National Committee for Quality Assurance (NCQA). specific actions or procedures related to compliance.</li><li>Efficiently perform all credentialing verification and Enrollment aspects with payers, including initial credentialing and re-credentialing to ensure current Enrollment and timely handoff.</li><li>Participate in the development of internal credentialing &amp; Enrollment processes&middot;</li><li>Keep records of licenses, credentials, insurance contracts and other documents of groups and individual providers. &middot;</li><li>Establish a robust monitoring system to track expiring licensures, board certifications, and professional certifications. Implement proactive measures for timely renewals to prevent any lapses.</li><li>Adhere to legal requirements for information release, ensuring compliance with privacy regulations. Clearly communicate the processes for releasing information to agencies and the public, emphasizing the importance of maintaining confidentiality. &middot;</li><li>Use critical thinking skills to conduct Research, follow-up with the Insurance companies.</li><li>Establish and communicate a clear timeline for responding to inquiries from clients, health plans, and internal stakeholders. Implement effective communication channels to ensure timely and comprehensive responses.</li><li>Regularly update and maintain the CAQH profiles of assigned providers. Address any challenges in ensuring the accuracy and completeness of profiles and implement strategies for ongoing profile maintenance.</li><li>Actively participate in team meetings and process improvement initiatives to continuously improve work product quality and efficiency.</li></ul>Job Type: Full-timePay: Up to Rs150,000.00 per monthWork Location: In person

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