Provider Credentialing Manager

San Mateo County, California
Depending on Experience
Aug 13, 2019
Oct 12, 2019
Job Type
Not Specified
Career Level

The Provider Credentialing Manager manages and oversees credentialing activities for HPSM’s provider network, including the oversight of providers for whom HPSM has delegated credentialing functions. Drive continuous improvement of credentialing and Provider Services’ departmental operations. Work closely with the HPSM Quality department to support oversight of provider quality, including managing corrective action of quality concerns, and promoting quality initiatives among providers to improve network performance on clinical and operational measures.

Essential Duties of this position include:

  • Accomplish staff results by communicating  job expectations; planning, monitoring, and appraising  job results; coaching, counseling, and implementing  corrective action steps when necessary; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards.  Complete performance evaluations in a timely manner.
  • Oversee credentialing for directly-credentialed providers in HPSM’s network in a thorough and timely manner, in compliance with regulatory requirements
  • Lead HPSM oversight of delegated credentialing activities among provider groups to whom HPSM has delegated this function. This includes ensuring regular reporting and auditing are conducted, and that corrective action is taken when needed with demonstrated improvement results.
  • Lead audit preparation and activities for NCQA, DMHC, DHCS, and CMS, for requirements related to HPSM’s credentialing and delegated function oversight.
  • Produce state and other regulatory reports on provider credentials and HPSM’s network as needed
  • Function as a liaison between HPSM and delegated provider groups. This will include leading process improvement work and strengthening leadership relationships.
  • Maintain ongoing knowledge of developing trends in healthcare and within managed care.
  • Analyze new or updated regulations, laws and contract language and implement appropriate changes to internal policies, procedures and workflows.
  • Lead the Credentialing Review Committee, Physician Advisory Committee and Peer Review Committee. This includes recruiting new internal and external committee members when needed, ensuring appropriate documentation of decisions and minutes is completed in a timely manner, developing materials and agendas, and leading the discussion in committee meetings.
  • Lead process improvement efforts within Provider Services and across departments on topics related to credentialing, delegated provider group oversight, and overall network quality.
  • Diplomatically and creatively resolve escalated or complex provider credentialing issues, using strong problem-solving and communication skills and approaching conflict resolution with humble curiosity and a bias to action.

Job Requirements

Bachelor’s degree required. Managed care contracting experience in healthcare environment dealing directly with payers, providers and intermediaries required.  Experience directing, managing, or supervising others to achieve results. Preferred experience operating high-performing delegated entity agreements with multi-specialty groups, County agencies and other provider types. Experience with provider credentialing activities preferred.

Skills and Knowledge

To be successful in this position will require that you possess the following:

  • Demonstrated knowledge and understanding of Managed Care, Medi-Cal and Medicare including regulations and requirements.
  • Strong knowledge of project management and process improvement methodologies.
  • Understanding of provider credentialing processes and tools.
  • Knowledge of quantitative reasoning and analytics tools.
  • Demonstrated proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
  • Knowledge of supervisory principles and practices as well as techniques and methods to organize and manage direct reports.
  • Strong interpersonal skills, establishing rapport and working well with others.
  • Strong customer service with excellent written and verbal communication skills.
  • Good influence management skills and ability to work with all levels of internal and external customers.
  • Excellent data analytics and reporting skills. 
  • Ability to work cross-functionally to execute network quality goals.
  • Ability to maintain accountability for regulatory compliance, often on short timeframes.
  • Ability to work independently and re-prioritize as needed to meet deadlines and department goals.


HPSM Benefits

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage.  Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits.  Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; Employee Wellness Program including onsite fitness center and more.

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