Credentialing Manager - Medical Staff Office - FT - Day

Position Status: Full time, First Shift (Days - Less than 12 hours per shift), 40 hours per week. Exempt.

About the Role

The Credentialing Manager leads strategies for the administrative and functional oversight of the credentialing and provider enrollment database to ensure a quality credentialing and privileging program. This role enhances the medical staff and team experience while meeting regulatory requirements (SVH Bylaws, TJC, NCQA, and other regulatory bodies). The Manager coordinates compliance with payer panels metrics, trended data stratification, and effective data utilization through an integrated stakeholder process for inpatient, outpatient, and ambulatory care services.

This position assists with daily tasks as directed by the Director of SVH Administration and the Medical Staff, collaborating with numerous departments across the organization. The Manager executes audit processes, delivers high-quality reports, and maintains communication throughout SVH while fostering relationships with management, governance, and accrediting bodies.

The Credentialing Manager supports the development, planning, and operational management of MD Staff (Credentialing, Privileging, Payer Enrollment), MD STAT (Peer Review, OPPE, FPPE), marketing, SVNET, and EPriv federal report builds. This role ensures program security and integrity in accordance with accrediting body standards and demonstrates expertise in medical staff bylaws, regulatory requirements, privileging, OPPE/FPPE, provider enrollment, governmental requirements (Medicare, Medicaid, etc.), and NCQA regulations.

Responsibilities

• Ensure accuracy of data in credentialing software and manage software systems.
• Compile, maintain, and analyze data; report recommendations for system improvements to the Director.
• Provide requested reports to internal and external customers.
• Research and develop drafts of delineation of privileges, OPPEs, FPPEs, and assist with presentation and approval.
• Supervise staff, including managing schedules, timekeeping, attendance records, and performance evaluations.
• Serve as the Lead for the Credentialing Team and act as the Director’s designee in their absence.
• Manage data for provider and clinician performance profiles, department/service line profiles, and ad hoc data queries.
• Provide data abstraction, analysis, and reporting of trends related to defined outcomes.
• Compile, analyze, and present clinical improvement information to organizational and medical staff committees.
• Maintain knowledge of evidence-based, CMS, and TJC clinical metrics; serve as a subject matter expert for clinical performance benchmarks and peer review processes.
• Ensure timely processing of applications and meet current goal timeframes.
• Educate and train credentialing staff on best practices and software usage.
• Serve as the subject matter expert in credentialing and privileging for all customers.
• Participate in delegated payer panel audits and educate the organization on MD-Staff software.
• Process credentialing files as directed.
• Comply with all Stormont Vail Health policies, standards, and mandatory training requirements.
• Perform other duties as assigned.

Requirements

• Associate’s Degree Required.
• Bachelor’s Degree or 5 years of direct medical staff office/credentialing privileging experience may be substituted for education Required.
• 5 years of medical staff credentialing experience Required.
• Proficiency in Microsoft Office Required.
• 3 years of working knowledge in credentialing software/process Required.
• 1 year of computer programming/data management experience for streamlining processes (e.g., initial, reappointment, FPPE, OPPE, Peer Review) Required.
• 1 year of leadership/supervisory experience Preferred.

Skills and Abilities

• Professional ethics, communication, and relationship-building.
• Analytical thinking and people management.
• Ability to read, analyze, and interpret professional journals, technical procedures, legal, accrediting, and regulatory information.
• Excellent writing skills for developing business correspondence, reports, and procedure manuals.
• Strong oral communication skills for representing and responding to information for diverse audiences (managers, physicians, regulatory agencies, customers, and the public).
• Ability to understand and communicate using appropriate medical terminology.
• Demonstrates respect for all individuals and fosters teamwork within the work environment.

Preferred Licenses and Certifications

• Certified Provider Credentialing Specialist (CPCS) – NAMSS.
• Certified Professional Medical Services Management (CPMSM) – NAMSS.
• MD-Staff Certified Specialist, Certification Level 2 years.

Schedule

On-site only. Workspace must be quiet and distraction-free to comply with security and privacy standards.

Physical Demands

• Sitting: Continuously greater than 5 hours.
• Standing/Walking: Occasionally 1-3 hours.
• Grasping (Fine Motor): Frequently 3-5 hours.
• Grasping (Gross Hand)/Handling: Frequently 3-5 hours.
• Talking/Hearing: Frequently 3-5 hours.
• Lifting/Pulling/Pushing: Rarely less than 1 hour, up to 10 lbs.
• Other: Rarely less than 1 hour for balancing, climbing, eye/hand/foot coordination, feeling, kneeling, reaching, stooping, and repetitive motions.

Working Conditions

• Noise/Sounds: Occasionally 1-3 hours.
• Dusts/Other Atmospheric Conditions: Rarely less than 1 hour.