Credentialing Manager at LSMA Management, Inc.

Description

JOB SUMMARY:

The Credentialing Manager is responsible for overseeing and managing the organization’s provider credentialing and recredentialing processes in accordance with regulatory, contractual, and accreditation standards. This role ensures the accuracy, completeness, and timeliness of credentialing activities across all lines of business, including Commercial, Medicare, and Medi-Cal. The Credentialing Manager works closely with internal departments, delegated entities, providers, and external agencies to support network compliance, delegated oversight, and operational readiness.

Additionally, the Credentialing Manager leads credentialing operations for the medical clinic and IPA, oversees staff, maintains credentialing systems, ensures compliance with NCQA and CMS standards, supports payor enrollment, and drives continuous process improvement to reduce onboarding delays and mitigate revenue and compliance risks.

Distinguishing Characteristics

Serves as the organization’s credentialing and delegated oversight subject-matter expert. Ensures provider network readiness, audit compliance, and timely payor activation to prevent reimbursement delays. Functions in a dual environment (clinic + IPA/MSO), managing differing regulatory and operational requirements. Represents the organization in health plan audits, oversight reviews, and credentialing committee governance. Leads credentialing staff while driving process improvements, accuracy, and standardization.

Essential Job Duties & Responsibilities

The following are exemplary essential job duties and responsibilities and are not intended to represent an all-inclusive listing of related essential functions of the position.

Credentialing Leadership & Operations

Lead and manage all aspects of provider credentialing, recredentialing, and privileging for physicians, allied health professionals, and facilities.

Ensure compliance with NCQA, CMS, DMHC, DHCS, and health plan-specific requirements, as well as internal organizational policies and procedures.

Oversee primary source verification, file completeness, and adherence to credentialing timelines.

Maintain current and accurate credentialing data across systems (e.g., CAQH, MD-Staff, VerityStream/CredentialStream, Modio, or other platforms).

Monitor expiring credentials (licenses, DEA, malpractice insurance, board certification, etc.) and ensure timely re-verification.

IPA & Delegated Credentialing Oversight

Oversee the preparation, accuracy, and submission of credentialing and roster files to contracted health plans and delegated entities.

Serve as the primary point of contact for delegated credentialing audits, regulatory reviews, and health plan oversight visits.

Ensure delegated activities meet NCQA, DHCS, Medicare Advantage, and health plan delegation requirements.

Maintain delegated credentialing policies, audit tools, dashboards, and corrective action plans when necessary.

Credentialing Committee & Governance

Manage the Credentialing Committee process, including preparing agendas, presenting files, creating minutes, documenting decisions, and following up on action items.

Ensure committee processes meet organizational bylaws, regulatory requirements, and accreditation standards.

Payor Enrollment & Network Readiness

Oversee payor enrollment and revalidation with Medicare (PECOS), Medi-Cal (PAVE), NPPES, CAQH, and commercial plans to support timely provider onboarding.

Collaborate with Revenue Cycle, Contracting, Provider Relations, and Operations to ensure providers are loaded correctly and activated on schedule.

Support provider directory accuracy and network integrity across all participating health plans.

Workflow Optimization & Compliance

Develop, implement, and monitor credentialing workflows that improve efficiency, accuracy, and turnaround times.

Create and maintain SOPs, audit tools, job aids, and training materials for the credentialing department.

Track and report key performance metrics (e.g., file completion rates, turnaround times, expirables compliance, payor enrollment delays)

Maintain complete, organized documentation required for internal audits, NCQA surveys, and delegated audits.

Cross-Functional Collaboration

Partner with Provider Relations, Contracting, Compliance, Quality, HR, IT, and Operations to ensure seamless provider onboarding and offboarding.

Support network expansion activities by communicating credentialing requirements and onboarding timelines to leadership and stakeholders.

Respond to internal and external credentialing inquiries and assist with escalations from providers, payors, or contracted partners.

Staff Supervision & Development

Supervise and support credentialing staff, providing ongoing training, coaching, mentorship, and performance feedback.

Assign and monitor workloads, ensuring timely completion of tasks and accurate processing of provider files.

Foster a collaborative, accountable, high-quality team culture focused on compliance and service excellence.

Other Work As Required/Requested

May be assigned special project or other assignments and work tasks that are generally within the scope and level of the position, and relative to the need for flexible Company operations.

Requirements

Education/Training

Minimum: Bachelor’s degree in healthcare administration, business, or related field.

Preferred: CPCS and/or CPMSM certification (NAMSS)

Experience

Minimum: Three to five years of credentialing experience in a managed care, IPA, MSO, medical group, or health plan environment. At least one year supervisory or management experience.

Preferred: Experience with delegated credentialing and health plan audits. Experience working with contracted provider networks or multi-site medical groups.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

• Knowledge of credentialing standards and regulatory requirements including NCQA, CMS, DMHC, DHCS, Medicare Advantage, and Medi-Cal.
• Knowledge of primary source verification processes and credentialing file components.
• Knowledge of delegated credentialing models and health plan delegation requirements.
• Knowledge of payor enrollment processes (PECOS, PAVE, NPPES, CAQH, commercial plans).
• Knowledge of credentialing software platforms and database management.
• Knowledge of medical staff bylaws, credentialing committee functions, and audit documentation standards.
• Strong analytical and organizational skills to manage complex data and workflows.
• Excellent written and verbal communication skills.
• Proficiency with credentialing and enrollment systems (CAQH, MD-Staff, CredentialStream, Modio).
• Strong leadership, training, and coaching skills.
• High accuracy and attention to detail in reviewing documentation and verifying data.
• Strong project management and multitasking in a deadline-driven environment.
• Ability to interpret and apply regulatory and accreditation standards.
• Ability to maintain confidentiality and handle sensitive provider information.
• Ability to work collaboratively across departments and with external partners.
• Ability to prioritize competing tasks and manage high-volume workloads.
• Ability to problem-solve and propose workflow improvements.
• Ability to represent the organization professionally during audits and committee meetings.
  
  

Physical, Mental & Environmental Requirements

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee will regularly be required to walk, stand, bend, lift and/or move up to 25 pounds. The employee is occasionally required to stand or stoop, kneel, crouch or crawl. The employee must exhibit the ability to assist patients with mobility, positioning, or transfers as needed. The employee may be exposed to bodily fluids, chemicals, and infectious materials with required PPE provided. Work is performed in a standard outpatient medical office, exam room, and clinical setting. Specific vision abilities required by this job include close, distance, color, peripheral vision, depth perception and the ability to adjust focus.