Credentialing Manager

Credentialing Manager

Credentialing Manager Department: Credentialing Reports To: Chief People Officer FLSA Status: Exempt Employment Type: Full-time Salary: $75,000–$85,000 Location: Remote; attend onsite meetings as needed

Position Summary: The Credentialing Manager serves as the organization's subject matter expert on credentialing, provider enrollment, and regulatory eligibility for employees and other providers delivering client services.

This role leads the credentialing program to ensure providers and applicable service locations meet Minnesota Department of Human Services (DHS), Early Intensive Developmental and Behavioral Intervention (EIDBI), and other applicable state, federal, and payer requirements. The manager ensures required qualifications, licensure, certifications, verifications, and enrollment approvals are completed and documented before providers deliver or bill for services that require them. The role also oversees ongoing monitoring to maintain provider eligibility and prevent lapses.

Responsibilities:

Credentialing Program Leadership • Lead credentialing across provider types, service lines, and locations to ensure compliance with applicable regulatory and payer requirements. • Develop and implement policies, standard operating procedures (SOPs), and workflows that define responsibilities, timelines, escalation procedures, and provider readiness checks. • Anticipate credentialing needs related to hiring, provider level changes, new services, and location changes. • Monitor program performance and lead improvements to prevent credentialing lapses and avoidable service or reimbursement delays. • Translate regulatory and payer changes into updated procedures, practical guidance, and staff training.

Staff Leadership and Supervision • Supervise, coach, and develop credentialing staff, setting clear expectations for accuracy, timeliness, communication, and follow-through. • Prioritize workloads, monitor deadlines and backlogs, and establish cross-training and backup coverage. • Provide regular feedback, address performance concerns, and reinforce consistent practices. • Foster collaboration, shared visibility, and timely escalation of questions, barriers, and risks.

Minnesota DHS and EIDBI Compliance Oversight • Confirm providers meet applicable qualification, enrollment, affiliation, and supervision requirements before delivering services that require those approvals. • Oversee DHS enrollment, affiliations, provider level changes, revalidation, and updates; verify approval status and effective dates. • Maintain accurate provider and location information in DHS systems, monitor agency communications, and promptly resolve discrepancies. • Coordinate applicable service-location enrollment and licensing requirements with Compliance and Operations.

Verification and Ongoing Compliance • Oversee primary source verification of provider licensure, education, certifications, and other required qualifications. • Maintain complete provider files, including applicable experience and supervision documentation. • Monitor renewals, required screenings, sanctions, and ongoing provider eligibility.

Commercial Payer Enrollment • Oversee payer applications, recredentialing, affiliations, and provider and location updates. • Track submissions, follow up with payers, and partner with Revenue Cycle to resolve discrepancies and escalate delays affecting services or reimbursement.

Data Management and Reporting • Maintain accurate credentialing records that clearly document ownership, provider readiness, deadlines, renewals, and approvals. • Use reports and dashboards to communicate progress, identify risks, prioritize work, and improve performance.

Audit Readiness and Collaboration • Review credentialing files, prepare for payer and regulatory audits, and coordinate the resolution of documentation gaps and compliance concerns. • Partner across departments to align onboarding, provider readiness, and billing requirements while maintaining shared visibility.

Performance Metrics Success in this role will be measured by: • Timely submissions, renewals, follow-up, and escalation to prevent avoidable credentialing lapses. • Provider readiness aligned with planned start dates and service needs. • Accurate, complete, and audit-ready credentialing records. • Timely resolution of audit findings and compliance concerns. • Effective staff development, workload management, and backup coverage. • Clear reporting on application status, turnaround times, backlogs, and risks. • Fewer preventable credentialing-related service delays and billing denials. This role helps protect the organization's ability to deliver services under Minnesota DHS programs and other regulated service models.

Qualifications:

Education and Experience • Associate degree in healthcare administration, business, or a related field, or an equivalent combination of education and relevant experience. • At least five (5) years of experience in healthcare credentialing, provider enrollment, regulatory compliance, or provider eligibility management. Regulatory and Payer Enrollment Experience • Experience with Minnesota DHS programs or comparable state healthcare regulatory frameworks, including provider enrollment and eligibility requirements. • Experience with Medicaid and commercial payer enrollment, recredentialing, provider affiliations, and ongoing provider data maintenance. Leadership and Process Improvement • Experience leading a team or managing credentialing operations, including assigning workloads, coaching staff, and maintaining accountability. • Demonstrated ability to develop and improve credentialing workflows, document procedures, and implement consistent practices.

Technical and Professional Skills • Strong knowledge of primary source verification, provider file management, and ongoing compliance monitoring. • Strong attention to detail, organizational and problem-solving skills, and follow-through on competing deadlines. • Clear communication and a collaborative approach to working with providers, payers, regulatory agencies, and internal teams. • Experience using credentialing systems, payer portals, and reporting tools to maintain accurate data, monitor performance, and communicate progress.

Preferred • Experience with EIDBI requirements, MN–ITS, and Minnesota provider enrollment systems. • Certified Provider Credentialing Specialist (CPCS) certification. • Experience in behavioral health or autism services.

Travel Limited travel.

Physical Demands • Prolonged periods of sitting at a desk. • Moderate use of a computer, keyboard, and mouse. • Bending to file or retrieve documents. • Occasional light physical effort. • Ability to lift and carry up to approximately 15 pounds.

About the Company: MAC Midwest is a nonprofit provider of coordinated neurodevelopmental care and a recognized leader in the field, with 30 years of experience serving individuals with autism and related conditions and their families across Minnesota. Through a comprehensive, transdisciplinary model, we provide diagnostic assessments, compassionate ABA therapy, mental health services, speech and occupational therapy, and family training. Our teams use clinical expertise and careful evaluation to develop individualized plans that support communication, independence, and long-term progress. We are committed to meeting each person right where they are through progressive and compassionate care, ensuring individuals and families receive the support they need at every stage. MAC is an Equal Opportunity Employer and does not discriminate in terms or conditions of employment on the basis of sex (including pregnancy, childbirth, and related medical conditions), race, traits associated with race (including hair texture and style), color, national origin, religion, creed, age once having reached the age of majority, sexual orientation, gender identity, gender expression, military status, veteran status, disability, marital status, familial status, genetic information, status with respect to public assistance, or any other characteristics that are protected by federal, state, or local laws.

Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.