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.

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)
• 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.