Credentialing Director Jobs in Rochester, NY (NOW HIRING)

Job Description:

Summary:

The Manager of Credentialing Operations has direct responsibility for managing the internal operational credentialing activities for the Health Plan. The Manager oversees the end-to-end credentialing process for healthcare providers in compliance with regulatory, accreditation, and organizational standards. This role manages daily operations, leads credentialing staff, and ensures timely verification, enrollment, and maintenance of provider credentials. They are responsible for monitoring performance metrics, enforcing quality standards, and driving process improvements to increase efficiency and ensure accuracy in provider data systems.

Essential Accountabilities:

• Accomplishes defined objectives and oversees all activities which relate to provider credentialing through effective planning, organization and utilization of personnel and equipment. Develops and implements department goals and corresponding action plans and monitors performance against these goals.

• Manage the full lifecycle of provider credentialing and recredentialing processes, ensuring timely and accurate completion, and maintain compliance with federal, state, and accreditation standards (NCQA, CMS, etc.) as well as internal policies.

• Supervise, train, and evaluate credentialing team members; provide coaching and support to drive productivity and quality.

• Provides direction and supervision for direct and indirect reports within the Credentialing team. Provides routine feedback on development, skills, and performance measurements.

• Identify opportunities to increase efficiency, reduce turnaround times, and implement best practices and automation where possible.

• Participate in audits related to credentialing data and processes, ensuring documentation accuracy and audit readiness.

• Monitor performance metrics/KPIs, enforce quality standards, policies and procedures, and ensure accuracy and completeness of credentialing data.

• Establishes and maintains working relationships with internal departments to ensure credentialing operations are functioning and communicated appropriately.

• Address complex credentialing issues, provider data discrepancies, and escalations in a timely manner, including system issues.

• Manage relationships with credentialing vendors or CVOs (Credentialing Verification Organizations).

• Participates in budget/invoice reviews as needed.

• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct and leading to the Lifetime Way values and beliefs.

• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.

• Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.

• Conducts periodic staff meetings to include timely distribution and education related to departmental and Ethics/Compliance information.

• Regular and reliable attendance is expected and required.

• Performs other duties and functions as assigned by management.

Minimum Qualifications:

• Minimum of three (3) years of credentialing, operations, or provider-related experience required.

• Minimum of five (5) years of progressive management experience with health care services and/or insurance, supported by a working knowledge of managed care principles and computer applications.

• Bachelor's degree in Business Administration or health care field; in lieu of degree, a minimum of six (6) years of additional credentialing, operations, or provider-related experience required.

• Prior experience supervising or managing people and/or projects or indirectly leading teams.

• Strong project and personnel management skills and organizational skills essential.

• Experience in analyzing system data, developing and testing requirements, and working with system users.

Physical Requirements:

• Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer.

• Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.

• Ability to travel across the Health Plan service region for meetings and/or trainings as needed.

• Ability to work in a home office for continuous periods of time for business continuity.

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In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Grade E5: Minimum $71,880 - Maximum $129,384

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.