Credentialing Lead in MISSION VIEJO, California at South Coast Children's Society

POSITION SUMMARY:

The Credentialing Lead is a highly specialized role focused on enrolling mental health providers into insurance networks, tracking state licenses, and responsible for overseeing and supporting the end-to-end credentialing process for eligible providers at all levels with contracted health plans. This role works collaboratively with Clinical, Billing, Human Resources, and Onboarding to maintain accurate participation status with all contracted health plans. The position requires strong skills in communication, CAQH, PAVE and Availity. A key focus of this role is ensuring data is consistently documented and maintained across all data sources and platforms, internally and externally, enabling more effective and scalable analytics across the organization.

This role reports to the Director of Contracting and Credentialing to deliver reporting and analysis that supports day-to-day operations and ongoing performance improvement.

JOB DUTIES & RESPONSIBILITIES:

Key Responsibilities Provider Enrollment

• Support and execute provider enrollments with all contracted health plans.
• Develop, maintain, and enhance the provider credentialing certification and enrollment processes
• Produce recurring and ad hoc reports to support credentialing operations.
• Ensure accuracy and consistency of reported data through validation and reconciliation processes.

Data Systems Documentation and Structure

• Maintain internal data reporting systems, provider attestation(s), including external data sources (e.g., CAQH, Availity and health plan provider portals).
• Maintain initial and reappointment provider credentialing
• Identify gaps or inconsistencies in data structures and escalate opportunities for improvement.
• Support the development and maintenance of data dictionaries and internal documentation resources.

Cross-Functional Support

• Liaison efforts externally with health plans and internally with including Human Resources, Onboarding, Billing, and Clinical Operations to streamline provider credentialing efforts.
• Present findings in a clear, concise manner appropriate for both administrative and clinical audiences.
• Perform regular audits to identify and report data inconsistencies and positive/negative trends.

QUALIFICATIONS

Education/Experience

• Minimum 1 year of team management
• 3 – 5 years of healthcare credentialing experience with an emphasis in behavioral health or similar role.

Preferred Qualifications

• Bachelor’s degree in healthcare administration or related discipline, preferred but not necessary
• Familiarity with EHR systems and healthcare data structures.
• Experience supporting cross-functional teams with reporting and analytics.

Required Knowledge and Skills

• Team Management experience working in healthcare or behavioral health environments.
• Strong proficiency in Availity and CAQH.
• Demonstrated ability to independently manage a high volume of responsibilities across multiple locations with minimal oversight.
• Exceptional organizational skills with a proven system for tracking, prioritization and timely execution.
• Experience building dashboards and visualizations in Excel and PowerPoint.
• Experience working with complex relational databases and multi-source data environments.
• Demonstrated ability to document data systems, reporting logic, and workflows clearly and accurately.
• Strong attention to detail and commitment to data accuracy and integrity.

WORK ENVIRONMENT

Role operates in a hybrid environment with occasional on-site presence in Southern California.

• The position involves access to sensitive data and requires adherence to HIPAA and organizational data security standards.
• Required to occasionally lift and carry 10 to 20 pounds.
• Valid California driver’s license, insurance and reliable transportation and CPR/First Aid certification within 30 days of hire.
• Regularly required to sit and use a computer and telephone for extended periods. Regularly required to stand, walk, and climb stairs. May be required to travel between SCCS sites and attend external meetings across San Bernardino and Orange Counties and beyond.

EOE, INCLUDING DISABILITY/VETS

We are an equal opportunity employer and consider all qualified applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, medical condition, genetic information, marital status, veteran status, or any other protected characteristic under California law.