Sr. Manager, Peer Review and Credentialing / Job Req 1040495936

About the role

Hybrid role: External applicants must be a California resident as of their first day of employment. Internal applicants must live in their current approved state (the 6 approved states: CA, AZ, NV, TX, WA, OR).

Responsibilities

• Manage oversight and supervision of credentialing and peer review staff to ensure compliance and timely processing of new provider and recredentialing applications.
• Serve as primary resource in credentialing, quality assurance/performance improvement credentialing requirements, and department and committee activities.
• Maximize the credentialing and peer review team’s efficiency, productivity, and performance by keeping employees accountable for meeting credentialing guidelines.
• Manage credentialing vendors including Cactus, CVO, and CAQH services; conduct audits on reports and files, review invoices for accuracy, and approve payment.
• Implement Corrective Action Plans when required.
• Perform periodic file audits to ensure credentialing procedures meet regulatory requirements and Alliance standards, and that credentialing files are complete.
• Manage ongoing reporting process that is accurate, timely, and action‑driven to support credentialing staff.
• Collaborate with the Chief Medical Officer to ensure that all significant malpractice cases, state/federal sanctions, and quality issues are reviewed prior to peer review.
• Manage ongoing monitoring as required by regulatory agencies.
• Interpret, develop, and implement practices of all credentialing systems and functions to ensure continuous compliance with applicable regulatory agencies and accrediting bodies (e.g., NCQA, DMHC, DHCS, CMS).
• Perform delegated entity annual credentialing audits and review quarterly credentialing reports as required by regulatory agencies; implement Corrective Action Plans as required; summarize and submit reports to CMO and Compliance Department as requested.
• Serve as primary contact for internal credentialing audits as required; act as a resource on credentialing regulatory requirements.
• Coordinate and submit the Peer Review and Credentialing Committee, including auditing files, preparing materials, preparing agenda, and conducting follow‑up from meetings.
• Manage and oversee that credentialing staff contact providers and outside agencies through written and verbal communication to obtain and prepare credentialing documentation for review, completion of application, or to update credentialing records.
• Contact providers through written and verbal communication to prepare credentialing documentation.
• Coordinate with Network Management and Quality Management department staff to ensure timely submission of grievances, quality issues, and facility site review data as part of recredentialing and on an ongoing basis.
• Ensure compliance with Alliance established policies and procedures, objectives, and Quality Improvement Program.
• Develop credentialing policies and procedures; review and update Alliance credentialing policies, workflows, and training manual annually and as needed.
• Coordinate the credentialing process with the Compliance department and Network Management.
• Manage maintenance of practitioner and organizational provider information in the Alliance information system and assure confidentiality of that information.
• Control costs and budgeting for the Credentialing department, ensuring funds are used appropriately.
• Oversee employee performance and responsible for employee improvement action plans.
• Complete special projects and other duties as assigned.
• Access a variety of sources including computer related sources and paper files; review information in files/computer and report details back to provider or Alliance staff as appropriate.
• Serve as liaison between the provider and health plan member.
• Prepare and administer presentations to providers for training and promotional purposes.
• Travel between the worksite and provider/delegated entity offices is required.
• Supervise and train staff.
• Perform writing, administration, analysis, and report preparation.
• Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal