Senior Credentialing & Peer Review Leader

Alameda Alliance; Alameda (CA); Hybrid; USD 181,000 - 272,000; Full time

Job summary

Alameda Alliance in California seeks a Sr. Manager, Peer Review and Credentialing to oversee credentialing for physicians and allied providers, supervise staff and vendors, and ensure compliance with NCQA, CMS, DHCS and DMHC standards.

You will conduct audits, manage annual credentialing reviews, collaborate with the Chief Medical Officer, develop policies, and monitor budgets while maintaining confidentiality of provider information.

Qualifications

• Minimum five years of credentialing experience in a health care setting.
• Experience supervising 1-3 staff.
• Knowledge of NCQA, CMS, DHCS, DMHC standards.
• NAMSS CPCS or CPMSM certification required.

Responsibilities

• Oversee credentialing and peer review staff to ensure timely processing of new provider and recredentialing applications.
• Manage credentialing vendors including Cactus, CVO, and CAQH services; audit reports and approve payments.
• Perform periodic file audits to ensure regulatory compliance and Alliance standards.
• Coordinate with the Chief Medical Officer to review significant malpractice cases, sanctions, and quality issues prior to peer review.
• Develop and update credentialing policies and procedures; maintain confidentiality of information.

Skills

Interpersonal communication

Persuasive communication

Leadership / supervisory

Credentialing experience

Regulatory knowledge

CMS/NCQA knowledge

Microsoft Office / Access

Education

BA/BS Degree

NAMSS CPCS/CPMSM

Tools

Microsoft Office

MS Access

Job description

Alameda Alliance in California seeks a Sr. Manager, Peer Review and Credentialing to oversee credentialing for physicians and allied providers, supervise staff and vendors, and ensure compliance with NCQA, CMS, DHCS and DMHC standards.

You will conduct audits, manage annual credentialing reviews, collaborate with the Chief Medical Officer, develop policies, and monitor budgets while maintaining confidentiality of provider information.