Manager, Quality Assurance (Credentialing)

Overview

The Manager, Quality Assurance will be responsible for overseeing the quality assurance function within the credentialing department; this includes developing and implementing quality assurance strategies, plans, and processes to ensure high quality standards are met for all credentialing and primary source verification activities. This role also provides oversight of delegation audits, sub delegation audits, sanctions monitoring, and credentialing data integrity reviews to ensure compliance with regulatory and accreditation requirements. Leads a team to conduct audits, identify issues, and drive continuous improvement across all credentialing and business operations processes.

Duties & Responsibilities

• Develop quality assurance plans and audit methodologies for credentialing operations, delegated entities, and subdelegated arrangements
• Lead and mentor a team of credentialing quality assurance specialists, providing guidance and oversight
• Conduct comprehensive delegation and sub delegation oversight audits to ensure compliance with NCQA, CMS, federal, and state requirements
• Oversee routine sanctions monitoring programs, including OIG, SAM, state exclusions, and license sanctions
• Perform credentialing information integrity audits to validate accuracy, completeness, and consistency of provider data across systems in accordance with NCQA standards
• Execute business operations audits to assess process effectiveness, identify gaps, and recommend improvements
• Collaborate with credentialing operations leadership to ensure quality standards and metrics are consistently met
• Define and track key quality metrics and proactively identify areas for improvement
• Ensure compliance with NCQA, CMS, federal, and state regulations related to credentialing and delegated oversight
• Stay current on industry trends, best practices, and tools for credentialing quality assurance
• Manage QA resources effectively and efficiently to meet department goals
• Foster a culture of quality, compliance, and continuous improvement within the credentialing department

Skills Required

• Bachelor’s Degree or an equivalent number of years of relevant experience
• Five years of experience in healthcare credentialing, including at least two years in a quality assurance role
• Strong knowledge of NCQA, CMS, federal, and state credentialing regulations and standards
• Proven track record of leading and mentoring quality assurance specialists
• Expertise in developing and executing credentialing quality assurance plans and audits, including delegated and subdelegated oversight
• Strong data analysis skills with the ability to identify trends and issues
• Excellent problem‑solving, communication, and leadership skills

Desired Skills and Qualifications:

• Experience with credentialing software and databases
• Lean Six Sigma or other process improvement certification
• Certified Provider Credentialing Specialist (CPCS) certification
• Experience with delegated credentialing oversight and sanctions monitoring programs
• Knowledge of provider enrollment and network management

Min

Max