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Alma · 2 hours ago

Credentialing Manager

United States

Contract

Remote

Mid, Senior Level

$110K/yr - $130K/yr

6+ years exp

Alma is on a mission to simplify access to high-quality, affordable mental health care. The Credentialing Manager is responsible for ensuring the organization's audit readiness and adherence to regulatory requirements related to delegated credentialing, while also leading initiatives to improve compliance and efficiency within the Revenue Cycle Management processes.

Health CareMedicalMental HealthWellness

Responsibilities

Serve as the subject matter expert and primary liaison for all insurance payer audits related to delegated credentialing agreements

Implement and maintain NCQA standards and requirements across all credentialing policies and procedures to uphold accreditation readiness and quality assurance

Design, implement, and maintain the Compliance Scorecard and KPIs for credentialing and RCM, demonstrating measurable improvement year-over-year

Ensure the organization is prepared for annual audits by developing a playbook and ensuring improvements based on any previous Corrective Action Plans (CAPs)

Work with Legal and Compliance to monitor changes in payer, state, and federal laws and rapidly update internal policies and Standard Operating Procedures (SOPs) accordingly

Lead compliance efforts within the RCM division, focusing on the regulatory intersections between credentialing, enrollment, and claims processing

Identify and eliminate bottlenecks in the Credentialing and RCM workflows, specifically targeting root causes of claim denials and credentialing delays to improve the Clean Claim Rate

Oversee the performance of any Credentials Verification Organization (CVO) partners and internal support partners to ensure their work meets NCQA and organizational quality standards

Ensure annual required trainings are completed for all RCM and Credentialing staff

Facilitate and support the Credentialing Committee, ensuring committee decisions are documented and adhered to in alignment with all policies and procedures

Act as a hands-on individual contributor when necessary, diving into operational details, troubleshooting issues, and executing complex tasks to drive continuous improvement

Qualification

Healthcare CredentialingNCQA StandardsRCM ComplianceCompliance ScorecardProject ManagementProcess ImprovementLeadershipCommunication SkillsOrganizational Skills

Required

Robust Credentialing Leadership: 6+ years of progressive experience in healthcare credentialing, with a significant portion dedicated to managing delegated functions

Delegated Credentialing Expertise: Deep, demonstrated experience supporting and managing delegated credentialing agreements, including familiarity with pre- and post-delegation audit requirements and payer submission processes

NCQA Proficiency: Deep understanding and practical experience with NCQA standards and their application to both credentialing files and quality committee structure

RCM Compliance & Behavioral Health Knowledge: Strong working knowledge of the Revenue Cycle Management process and the regulatory nuances specific to mental/behavioral health services (e.g., medical necessity documentation)

Compliance Measurement: Proven experience establishing, monitoring, and reporting compliance KPIs and scorecards

Project Management & Organization: Exceptional organizational and project management skills with a demonstrated ability to manage complex, detailed, and timeline-driven compliance projects independently

Proven ability to interpret complex regulatory language (NCQA, CMS, etc.) and translate it into operational workflows

6+ years of progressive experience in healthcare credentialing, with a focus on managing delegated functions