Manager, Provider Data Management & Credentialing

Centene Corp.; Northern (KY); Hybrid; USD 88,000 - 158,000; Full time

Job summary

Centene Corp. seeks a senior leader to manage credentialing and provider data management across multiple business units.

You will ensure NCQA, DHHS and CMS compliance, oversee provider setup for claims and directory display, and drive cross-functional initiatives in network expansion and contract amendments. You will lead a team, monitor sanctions, review policies, and participate in quality improvement activities to raise efficiency and reduce costs.

Qualifications

• Bachelor’s degree or equivalent experience required.
• 5+ years of combined management and provider data management, credentialing, or healthcare operations experience.
• Leadership experience with cross-functional teams on large projects.
• Experience in managed care or insurance environments preferred.

Responsibilities

• Oversee credentialing and re-credentialing of physicians, mid-level practitioners, and organizational providers across multiple units.
• Oversee provider setup processes for accurate, timely claims payment, member assignment, and directory display.
• Ensure NCQA, DHHS, CMS and other regulatory compliance in credentialing activities.
• Collaborate with health plans and departments on network expansion, large claims, and contract amendments.
• Identify opportunities to reduce costs, improve quality, and increase department efficiency.
• Review and update departmental policies to meet NCQA, CMS, HCFA regulations.
• Monitor Medicaid and Medicare sanctioning reports for compliance.
• Facilitate Credentialing Committee activities and participate in Quality Improvement Committees as needed.

Skills

Credentialing leadership

Regulatory compliance

Process improvement

Cross-functional collaboration

Staff supervision

Education

Bachelor’s degree

Job description

**Position Purpose:** Manage the operations of all credentialing and provider data management functions for multiple business units ensuring compliance with National Committee for Quality Assurance (NCQA), Department of Health and Human Services (DHHS), Center of Medicaid/Medicare Services (CMS) and other regulatory standards. **Key Details:** Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT. * Oversee the credentialing and re-credentialing of all physicians, mid-level practitioners and organizational providers according to the plan specifications for multiple business units.* Oversee the provider setup processes ensuring accurately and timely setup for claims payment, member assignment and directory display.* Ensure compliance with NCQA and DHHS credentialing requirements and participate in activities related to plan NCQA accreditation.* Collaborate with the health plans and various departments on network expansion efforts, large claims and contract amendment projects and various related initiatives.* Identify process improvement opportunities to decrease cost, improve quality and increase efficiency within the department.* Review and update departmental policies and procedures to ensure compliance with NCQA, CMS and other regulatory agencies.* Monitor Medicaid and Medicare sanctioning reports to ensure compliance with Health Care Financing Administration (HCFA) requirements regarding prohibition of excluded provider participation.* Facilitate Credentialing Committee activities and serve on Quality Improvement Committees, when needed.**Education/Experience:** Bachelor’s degree in related field or equivalent experience. 5+ years of combined management and provider data management, credentialing or healthcare operations (i.e. claims processing, billing, provider relations or contracting) experience, preferably in a managed care or insurance environment. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.Pay Range: $87,700.00 - $157,800.00 per year