Manager, Credentialing (Information Technology)

Title: Manager, Credentialing
Reports to: VP, Credentialing and Billing
Classification: Manager
Location: Boston (Hybrid)
Job description revision number and date: V: 3.0; 04.07.2025

Organization Summary:
Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We are a fast-growing organization founded in 2016 and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices in Massachusetts and across the country. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.

Job Summary:
The ideal candidate will have a strong background in credentialing processes, including the use of credentialing software, and managing requirements for insurance payers and government programs such as Medicare and Medicaid. This role is crucial in ensuring that participating FQHC organizations providers meet all qualifications and maintain active participation with payers and regulatory bodies. Primary goal is to make sure that all provider types are enrolled and recredentialled with payers timely to minimize and delay in scheduling or seeing patients or related denials due to credentialing. The Credentialing Manager will work closely with the Billing/Accounts Receivable Manager, Revenue Integrity Manager, and directly with FQHCs /providers to align on timeline data collection and submission.
Responsibilities:

Oversee and manage all aspects of provider credentialing, re-credentialing, and payer enrollment processes for participating FQHCs and manage a team of professionals that support these functions
Supervise and support the credentialing team, providing training and guidance to ensure high standards of accuracy and productivity
Conduct regular performance evaluations and foster a collaborative team environment
Develop and implement policies and procedures to improve credentialing efficiency and compliance
Help create the vision for C3 to be the go-to resource for an affordable and efficient MSO in Billing and credentialing Accountable for all aspects of provider credentialing and enrollment to ensure provider data is loaded appropriately in all relevant systems. This includes understanding and communicating unique arrangements and ensuring the third-party payors accurately credential the provider
Maintain up-to-date knowledge of credentialing standards, FQHC-specific requirements, and Massachusetts state regulations
Monitor and address any issues related to provider enrollment, participation status, or payment related issues
Establish appropriate credentialing point of contacts at each payer to help facilitate the process and reconcile any outstanding items impacting the enrollment of a provider
Troubleshoot complex cases that fall outside routine processing
Provides direction, support, cross training and back-up for the entire credentialing team
Evaluate and recommend software to support efficient and affordable processes
Document workflow processes showing clear lines of accountability for those functions that are managed by the C3 Shared Service Team from those provider supporting functions that remain the responsibility of the FQHCs
Work closely with the billing department to align on provider status to ensure accurate billing and effective denial management
Manage and monitor user access for all related software and credentialing tools
Manage and utilize credentialing software and tools to complete and streamline credentialing/enrollment workflows
Maintain and update provider profiles in credentialing databases, EPIC, and other relevant systems
Maintain the Provider Enrollment Table (PET) in Epic to reflect the most current status of a provider with a payer; ensure that practice, provider and payor related tables are properly working
Develop reports and utilize Epic WQs and dashboards to track credentialing status, timelines, quality, productivity, and compliance metrics
Ensure compliance with all federal, state, and payer-specific credentialing requirements
Maintain accurate and secure records of provider credentials, licenses, certifications, and other required documents
Prepare for audits and reviews by regulatory agencies and payers, ensuring all documentation is current and accessible
Collaborate closely with providers, clinical leadership, and administrative teams to obtain required information and ensure credentialing deadlines are met
Coordinate with FQHCs, providers, licensing agencies, insurance carriers, and other organizations to complete the enrollment process
Work with various departments to ensure a smooth transition of providers when onboarding and for new contracts
Liaise with payers, regulatory bodies, and software vendors to resolve issues and enhance processes
Function as a resource and subject matter expert for internal stakeholders regarding credentialing and enrollment requirements
Work with incumbent credentialing and contract vendors for a smooth transition of process ownership

Required Skills:

Must have knowledge of credentialing principals, particularly those associated with medical groups and insurance companies
Knowledge of physician and allied practitioner credentialing processes
Requires the ability to work with and maintain confidential information
Ability to navigate credentialing information management systems to perform analysis and generate reports
Strong knowledge of Massachusetts healthcare billing regulations and payer requirements
Strong leadership, excellent communication skills across stakeholders, attention to detail, and critical thinking skills
Results driven and outcome focused
Must be innovative, comfortable with ambiguity, well-organized, and committed to moving quickly and collaboratively in the context of a rapidly changing organization
Ability to work independently
Experience with quality improvement/change management and project management
Proficiency in Microsoft Office Suite
Must have a strong commitment to quality assurance and exceptional customer service
A strong commitment to the organizations mission

Desired Other Skills:
Epic experience preferred
Familiarity with the MassHealth ACO program
Experience working in Federally Qualified Health Centers (FQHC)
Certifications such a Certified Provider Credentialing Specialist (CPCS) Certified Professional in Medical Staff Service Management (CPMSM) and/or National Association of Medical Staff Services (NAMSS) certification are a plus
Experience with and knowledge of CAQH and credentialing processes
Knowledge of NCQA and URAC accreditation standards
Experience with anti-racism activities, and/or lived experience with racism is highly preferred

Qualifications:
Bachelors degree in healthcare administration, business, finance, or a related field preferred
A minimum of 5 years of experience in credentialing, healthcare billing, with at least 2 years in a managerial role

** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **