Credentialing Manager at LSMA Management Inc – San Bernardino, California

JOB SUMMARY:

The Credentialing Manager is responsible for overseeing and managing the organization’s provider credentialing and recredentialing processes in accordance with regulatory, contractual, and accreditation standards. This role ensures the accuracy, completeness, and timeliness of credentialing activities across all lines of business, including Commercial, Medicare, and Medi-Cal. The Credentialing Manager works closely with internal departments, delegated entities, providers, and external agencies to support network compliance, delegated oversight, and operational readiness.

Additionally, the Credentialing Manager leads credentialing operations for the medical clinic and IPA, oversees staff, maintains credentialing systems, ensures compliance with NCQA and CMS standards, supports payor enrollment, and drives continuous process improvement to reduce onboarding delays and mitigate revenue and compliance risks.

MINIMUM & PREFERRED QUALIFICATIONS:

Education/Training

Minimum: Bachelor’s degree in healthcare administration, business, or related field.

Preferred: CPCS and/or CPMSM certification (NAMSS)

Experience

Minimum: Three to five years of credentialing experience in a managed care, IPA, MSO, medical group, or health plan environment. At least one year supervisory or management experience.

Preferred: Experience with delegated credentialing and health plan audits. Experience working with contracted provider networks or multi-site medical groups.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Skills, Knowledge & Abilities

· Knowledge of credentialing standards and regulatory requirements including NCQA, CMS, DMHC, DHCS, Medicare Advantage, and Medi-Cal.

· Knowledge of primary source verification processes and credentialing file components.

· Knowledge of delegated credentialing models and health plan delegation requirements.

· Knowledge of payor enrollment processes (PECOS, PAVE, NPPES, CAQH, commercial plans).

· Knowledge of credentialing software platforms and database management.

· Knowledge of medical staff bylaws, credentialing committee functions, and audit documentation standards.

· Strong analytical and organizational skills to manage complex data and workflows.

· Excellent written and verbal communication skills.

· Proficiency with credentialing and enrollment systems (CAQH, MD-Staff, CredentialStream, Modio).

· Strong leadership, training, and coaching skills.

· High accuracy and attention to detail in reviewing documentation and verifying data.

· Strong project management and multitasking in a deadline-driven environment.

· Ability to interpret and apply regulatory and accreditation standards.

· Ability to maintain confidentiality and handle sensitive provider information.

· Ability to work collaboratively across departments and with external partners.

· Ability to prioritize competing tasks and manage high-volume workloads.

· Ability to problem-solve and propose workflow improvements.

· Ability to represent the organization professionally during audits and committee meetings.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:

The physical demands described here are represented of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee will regularly be required to walk, stand, bend, lift and/or move up to 25 pounds. The employee is occasionally required to stand or stoop, kneel, crouch or crawl. The employee must exhibit the ability to assist patients with mobility, positioning, or transfers as needed. The employee may be exposed to bodily fluids, chemicals, and infectious materials with required PPE provided. Work is performed in a standard outpatient medical office, exam room, and clinical setting. Specific vision abilities required by this job include close, distance, color, peripheral vision, depth perception and the ability to adjust focus.