Job SummaryThe
Credentialing Lead is responsible for Credentialing Committee Preparation, overseeing the complete lifecycle of provider credentialing, including file review, verification, committee preparation, and ongoing monitoring. This role ensures compliance with NCQA, TJC, CMS, State regulations, organizational policies, and delegated credentialing requirements. The Supervisor leads staff, manages workflows, ensures quality, and supports timely onboarding and committee readiness.
Responsibilities- Key Responsibilities
Credentialing Committee & Compliance Oversight
- Oversee preparation of credentialing packets for all meetings, ensuring accuracy, completeness, and regulatory alignment.
- Present all files, terminations, meeting minutes, and new business items to the Credentialing Committee, ensuring materials are complete and compliant.
- Manage agendas, meeting schedules, follow-ups, minutes, and voting documentation.
- Collaborate with Medical Directors to finalize meeting materials, especially for redflagged providers.
- Oversee all delegated credentialing compliance requirements, including coordination of annual audits and preparation of semiannual delegation reports, ensuring accuracy, timely submission, and adherence to regulatory and contractual standards.
- Supervise the management of credentialing expirables, ensuring all licenses, certifications, and required documents are monitored, updated, and addressed in a timely and compliant manner.
Application Review & Verification
- Review all credentialing applications for completeness, log required information and request missing documentation.
- Critically evaluate applications for discrepancies, red flags, or qualityofcare concerns and escalate when appropriate.
- Perform comprehensive primary source verification (PSV) for licensure, DEA, board certification, NPDB, education/training, malpractice history, and other required elements.
- Track and follow up on all outstanding verifications to ensure timely completion.
Monitoring & Compliance
- Oversee monthly monitoring activities (licensing boards, OPMC, OMIG, OIG/SAM, Medicare OptOut) to ensure prompt identification and documentation of adverse actions.
- Monitor the full credentialing lifecycle - initial appointment, reappointment, expirables, and ongoing monitoring - to ensure compliance with regulatory and delegated standards.
- Ensure secure handling and confidentiality of all credentialing and committee materials.
Leadership & Operational Oversight
- Serve as a key liaison to Operations, People and Culture, and Malpractice Departments, ensuring seamless information-sharing, timely updates, onboarding coordination, and collaboration on provider readiness and risk-related matters.
- Supervise and mentor Credentialing staff; monitor workload and performance standards.
- Provide training on credentialing requirements, verification processes, and committee procedures.
- Conduct file audits to ensure accuracy and quality.
- Coordinate with onboarding staff, internal departments, and compliance teams to support provider readiness.
- Prepare verificationrelated payment requests.
- Utilize credentialing databases to track status, outcomes, and followup tasks; prepare reports and dashboards for leadership.
QualificationsQualificationsRequired - 3-5 years of healthcare credentialing or medical staff services experience.
- 1-2 years of supervisory or team lead experience.
- Strong knowledge of NCQA, TJC, CMS, and State regulatory standards.
- Excellent attention to detail, organization, and ability to manage multiple priorities.
- Strong communication skills and ability to work with executive and clinical leadership.
Preferred - Certified Notary - New York State
- CPCS or CPMSM certification (or willingness to obtain).
- Experience with credentialing systems (MD Staff, Medallion, Passport, MD Staff, Modio, etc.)
Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
Position Type and Expected Hours to Work: Full-Time Position
Monday through Friday from 9:00 a.m. to 5 p.m. - 40 hours work week
Travel: No travel is expected or required for this position.
Supervisor Responsibility: As described above.
