Director of Credentialing - Managed Care

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

Job summary

Johns Hopkins Health Plans, a part of Johns Hopkins Medicine, is seeking a Director of Credentialing who will lead credentialing activities across Medicaid, Medicare, commercial and TRICARE lines. The role focuses on NCQA/COMAR/CMS compliance, vendor relationships, and end-to-end onboarding and re-credentialing processes.

The position reports to the Executive Director, Health Services and requires collaboration with IT and key leadership teams.

Qualifications

• Bachelor's degree required; Master’s preferred.
• Minimum 7 years in a managed care health plan with credentialing experience.
• 3+ years in a management capacity.

Responsibilities

• Ensure compliance with credentialing regulations and standards.
• Oversee CVO vendor partner activities and SLAs.
• Collaborate with IT to improve onboarding, updates and reporting.
• Coordinate with Provider Data Management and Contracting for onboarding processes.
• Lead credentialing department and foster a compliant culture.
• Develop and enforce departmental policies; oversee QA and re-credentialing.

Skills

Regulatory compliance

Credentialing experience

Vendor management

Leadership

Education

Bachelor's Degree in Business Administration / Management or related field

Master's Degree

Job description

Ideally, this is a hybrid role with one day in the office on Wednesdays. We are flexible to a remote situation if you live outside of 60 miles but you would have to reside in one of our approved/registered states.

Reporting to the Executive Director, Health Services, the Director of Credentialing is responsible for all credentialing management activities for Medicaid, Medicare, Commercial and Tricare lines of business. The Director assures that all Credentialing activities are performed within the credentialing specifications of National Committee for Quality Assurance (NCQA) guidelines, Code of Maryland Regulation (COMAR), CMS, and US Family Health Plan (USFHP) Tricare regulations. This position also ensures credentialing practices are also consistent with industry practice standards. The Director owns the key vendor relationships supporting the credentialing function, including the credentialing system of record vendor and the credentials verification organization (CVO) vendor.

Johns Hopkins Health Plans (JHHP) is the managed care and health services business of Johns Hopkins Medicine. JHHP is a $3.2B business serving nearly 500,000 members with lines of business in Medicaid, Medicare, commercial, military health, health solutions, and venture investments. JHHP is a leader in provider sponsored health plans—backed by the clinical expertise of Johns Hopkins Medicine—and is poised for future growth.

Essential Functions

• 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.

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)

What We Offer

Johns Hopkins Health Plans is an organization that recognizes and rewards excellence and encourages professional development. Employee rewards, recognition, camaraderie and support are just a few of our many benefits include tuition assistance, dependent college tuition program, 403(b) retirement savings, health, dental vision and prescription coverage, disability and life insurance, paid time off and holidays.

Salary Range: Minimum 162,206.00/annually - Maximum 191,108.00/annually. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility. In cases where the range is displayed as a $0 amount, salary discussions will occur during candidate screening calls, before any subsequent compensation discussion is held between the candidate and any hiring authority.

The Hospital reserves the right to modify employee schedules as needed.

We are committed to creating a welcoming and inclusive environment, where we embrace and celebrate our differences, where all employees feel valued, contribute to our mission of serving the community, and engage in equitable healthcare delivery and workforce practices.

Johns Hopkins Health System and its affiliates are drug-free workplace employers.