Director of Credentialing & Compliance

Johns Hopkins Medicine; Hanover (MD); On-site; USD 162,000 - 191,000; Full time

Benefits offered by this job

Tuition assistance

Dependent college tuition program

403(b) retirement savings

Health, dental vision and prescription

Disability and life insurance

Paid time off and holidays

Job summary

Johns Hopkins Health Plans seeks a Director of Credentialing to oversee all credentialing activities across Medicaid, Medicare, Commercial and Tricare lines, ensuring adherence to NCQA, COMAR, CMS, and USFHP regulations.

The role owns key vendor relationships, collaborates with IT and provider data teams, and leads quality assurance from application through re-credentialing to support compliant enrollment processes.

Qualifications

• Bachelor's Degree in Business Administration / Management or related field (Required).
• Master's Degree (Preferred).
• Minimum of 7 Years of experience in a managed care health plan environment with credentialing experience (Required).
• 3 Years of experience in a management capacity role (Required).
• CPCS – Cert Provider Credentialing Spec 10000334 (Preferred).
• Certified Lean Six Sigma 10000291 (Preferred).

Responsibilities

• Ensures compliance with all relevant regulations and industry standards pertaining to credentialing/re-credentialing.
• Serves as the relationship owner of JHHP’s credentials verification organization (CVO) vendor partner, ensuring that all primary source verification day-to-day CVO activity is completed in accordance with JHHP’s contract and standard quality and turnaround time and other SLA requirements.
• Works collaboratively with IT to identify and implement enhanced systems and processes for onboarding, updates, and reporting to ensure efficiency and accuracy.
• Works collaboratively with Provider Data Management, Provider Relations, Provider Contracting to ensure the end-to-end provider onboarding and maintenance process operates effectively.
• Works collaboratively with senior leadership and key stakeholder teams to prioritize and successfully implement geographic expansion or other special projects related to credentialing.
• Oversees the delegated credentialing organizations to ensure agreements are updated and executed upon timely and that JHHP receives timely and accurate information for provider enrollment and changes to demographic information.
• Serves as the network’s subject matter expert on credentialing standards including NCQA along with federal and state regulations; maintains current knowledge of industry standards and best practices.
• Leads the Credentialing Department in accordance with JHHP values and instills a culture of compliance across the team.
• Develops and institutes departmental policies and procedures; advises on applicable changes and monitors compliance with established policies and procedures. Implements ongoing quality assurance program to ensure quality standards are adhered to from initiation of an application through appropriate re-credentialing/revalidation process.

Education

Bachelor's Degree in Business Administration / Management

Master's Degree

CPCS – Cert Provider Credentialing Spec 10000334

Certified Lean Six Sigma

Job description

Johns Hopkins Health Plans seeks a Director of Credentialing to oversee all credentialing activities across Medicaid, Medicare, Commercial and Tricare lines, ensuring adherence to NCQA, COMAR, CMS, and USFHP regulations.

The role owns key vendor relationships, collaborates with IT and provider data teams, and leads quality assurance from application through re-credentialing to support compliant enrollment processes.