Credentialing & Payer Operations Manager

Key Responsibilities

Provider Onboarding, Licensing & Doula Readiness

Manage full lifecycle licensing, credentialing, and re-credentialing applications for all Care Team members across multiple states.
Build and execute Doula Readiness workflows to onboard non-traditional care providers efficiently into payer networks.
Collect, audit, and verify primary source documentation required for payor and state credentialing packages.
Directly communicate with providers to gather missing documentation, guide them through state renewal procedures, and clear onboarding bottlenecks.

Licensure Maintenance, Certifications & CEU Tracking

Proactively monitor and track all clinical and non-clinical staff credentials, state license expiration dates, BLS/CPR certifications, and mandatory Continuing Education Units (CEUs).
Build structured automated workflow reminders in Medallion to advise care team members on upcoming renewal deadlines and mandatory continuing education requirements.
Audit and record completion certificates for required clinical trainings, state-mandated CEUs, and specialty accreditations prior to credential expiration.
Process Operations, Systems & Performance

Establish, standardize, and optimize internal credentialing and payer enrollment processes from scratch.
Own and maintain the credentialing management platform (Medallion) for automated tracking, expiration alerts, and primary source verification reporting.
Track and optimize key operational KPIs, specifically driving down Time-to-Credentialing to accelerate provider deployment and revenue generation.
Generate regular performance analytics and status reports for leadership regarding provider readiness and enrollment pipelines.

Revenue Cycle Management (RCM) & Payer Relations

Oversee the credentialing-to-claims bridge, ensuring providers are properly linked to billing systems prior to service delivery to prevent claim denials.
Submit credentialing packages directly to commercial insurance plans, Medicaid entities, and managed care organizations.
Partner closely with Revenue Cycle Management (RCM), billing, and coding teams to troubleshoot credentialing-related claims issues or enrollment delays.

Regulatory Compliance & Risk Management

Monitor state licensure bodies, OIG exclusions, Medicaid/Medicare sanction reports, and the National Practitioner Data Bank (NPDB) to ensure clean provider rosters.
Stay up to date on evolving healthcare regulations, state licensing requirements, HIPAA guidelines, and payer-specific enrollment rules.
Manage client-facing compliance reporting, delivering accurate documentation to meet health plan and enterprise client audit standards.

Client Communication & Stakeholder Alignment

Serve as the functional point of contact for enterprise clients regarding provider panel status and credentialing timelines.
Collaborate internally with Implementation and Client Success teams to align provider availability with client go-live targets.

Qualifications

5+ years of healthcare credentialing, provider operations, and payer enrollment experience.
Proven experience submitting initial state licensure applications across multiple states simultaneously and tracking recurring certification/CEU requirements.
Bachelor’s degree in Healthcare Administration, Business, or related field (Associates degree accepted with equivalent hands-on experience).
Hands-on experience with Medallion (or similar credentialing tracking platforms) is strongly preferred.

Key Skill Sets

Strong project management skills to track dozens of active licenses, BLS certifications, CEU deadlines, and payer files simultaneously.
Comfortable operating independently, solving complex payer delays, and building processes without a pre-existing playbook.
Excellent verbal and written skills for interfacing with providers, health plan representatives, internal billing teams, and enterprise clients.
Practical understanding of how credentialing linkages directly impact billing cycles and claims reimbursement.