Credentialing Manager Jobs in Mequon, WI (NOW HIRING)

Job Description

What You'll Do

• Serve as the organizational lead for NCQA Credentialing and Recredentialing (CR) standards, ensuring policies, procedures, files, and oversight activities meet accreditation requirements.

• Lead annual NCQA readiness assessments and mock surveys for Credentialing, Member Experience, and other accreditation standards to ensure continuous survey readiness.

• Support oversight of credentialing delegates and vendors, including performance monitoring, annual audits, corrective action plans, and reporting to credentialing governance committees.

• Partner with Credentialing Operations, Network Management, other business areas and delegated entities to ensure ongoing compliance with NCQA CR standards and credentialing-related regulatory requirements.

• Lead preparation for and participation in NCQA Credentialing File Reviews, including file selection, audit readiness assessments, corrective actions, and survey response development.

• Lead planning, execution, and oversight of NCQA Health Plan Accreditation programs, ensuring alignment with organizational goals and timelines

• Develop and maintain the NCQA program work plan and tracking tools to monitor progress, risks, and compliance status

• Coordinate NCQA survey activities, including documentation management, submission readiness, and stakeholder engagement

• Serve as subject matter expert (SME) on NCQA standards, with emphasis on Member Experience and Credentialing/Recredentialing (CR)

• Interpret standards and partner with business owners to operationalize requirements and implement compliant processes

• Identify gaps and risks; develop mitigation strategies and provide regular status reporting to leadership

• Conduct ongoing readiness reviews, audits, and monitoring activities to ensure sustained compliance

• Collaborate with business areas and cross-functional stakeholders to develop and finalize NCQA data source submission reports (e.g., Member Experience [ME 7]), ensuring accuracy, completeness, and alignment with NCQA standards and audit expectations

• Oversee delegated vendor functions to ensure adherence to NCQA accreditation requirements

• Facilitate cross-functional workgroups, committee discussions, and Quality Improvement meetings to drive accountability and readiness

• Establish and track performance metrics (process, outcome, and compliance measures) and present findings to stakeholders

• Drive continuous improvement initiatives to enhance quality, efficiency, and accreditation outcomes

• Analyze policies, workflows, and documentation to improve effectiveness and ensure regulatory alignment

• Support additional accreditation and compliance initiatives as needed

What You Bring

• Bachelor's degree or equivalent experience

• 3+ years of experience in related field

• In lieu of degree, 5+ years of experience in related field

Bonus Points (preferred qualifications)

• 5+ years of program or project management experience in healthcare, quality, or compliance

• Demonstrated experience preparing for and supporting NCQA surveys, file reviews, and accreditation submissions.

• Strong working knowledge of health plan credentialing operations, delegated credentialing oversight, and provider network compliance requirements.

• Experience leading cross-functional accreditation workgroups and driving corrective action plans through completion.

• Direct experience with NCQA Health Plan Accreditation standards and survey processes

• Experience supporting or managing Credentialing and Recredentialing (CR) activities

• Proven ability to manage cross-functional initiatives and drive results in a matrixed environment

• Strong understanding of accreditation compliance, evidence documentation, and audit readiness

• Ability to assess compliance gaps and implement actionable solutions

• Excellent analytical, organizational, and problem-solving skills

• Strong communication skills with the ability to influence stakeholders at all levels

• Proficiency in Microsoft Excel, PowerPoint, Teams, and SharePoint

• High attention to detail with strong program tracking and reporting capabilities

WhatYou'llGet

• The opportunity to work at thecutting edgeof health care delivery with a teamthat'sdeeply invested in the communityWork-life balance, flexibility, and the autonomy to dogreat work

• Medical, dental, and vision coverage along withnumeroushealth and wellness programs

• Parental leave and support plus adoption and surrogacyassistance

• Career development programs and tuition reimbursement for continued education

• 401k match including an annual company contribution

• Learn more

Salary Range

At Blue Cross NC, we take great pride in a fair and equitable compensation package that reflects market-price and our starting salaries are typically planned near the middle of the range listed. Compensation decisions are driven by factors including experience and training, specialized skill sets, licensure and certifications and other business and organizational needs.Our base salary is part of a robust Total Rewards package that includes an Annual Incentive Bonus*, 401(k) with employer match, Paid Time Off (PTO), and competitive health benefits and wellness programs.

*Based on annual corporate goal achievement and individual performance.

Skills

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