Manager, Provider Data Management & Credentialing

Position Purpose: Manage the operations of all credentialing and provider data management functions for multiple business units ensuring compliance with National Committee for Quality Assurance (NCQA), Department of Health and Human Services (DHHS), Center of Medicaid/Medicare Services (CMS) and other regulatory standards.

Key Details: Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT.

• Oversee the credentialing and re-credentialing of all physicians, mid-level practitioners and organizational providers according to the plan specifications for multiple business units.
• Oversee the provider setup processes ensuring accurately and timely setup for claims payment, member assignment and directory display.
• Ensure compliance with NCQA and DHHS credentialing requirements and participate in activities related to plan NCQA accreditation.
• Collaborate with the health plans and various departments on network expansion efforts, large claims and contract amendment projects and various related initiatives.
• Identify process improvement opportunities to decrease cost, improve quality and increase efficiency within the department.
• Review and update departmental policies and procedures to ensure compliance with NCQA, CMS and other regulatory agencies.
• Monitor Medicaid and Medicare sanctioning reports to ensure compliance with Health Care Financing Administration (HCFA) requirements regarding prohibition of excluded provider participation.
• Facilitate Credentialing Committee activities and serve on Quality Improvement Committees, when needed.

Education/Experience: Bachelor’s degree in related field or equivalent experience. 5+ years of combined management and provider data management, credentialing or healthcare operations (i.e. claims processing, billing, provider relations or contracting) experience, preferably in a managed care or insurance environment. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

Pay Range: $87,700.00 - $157,800.00 per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
 

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.  Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act