Licensing and Credentialing Manager

About the role

This position is responsible for ensuring all providers can legally practice and be reimbursed by payers. You will manage the systems that keep providers licensed, enrolled, and ready for revenue generation across all states and payer networks. This is a remote, individual contributor role without direct reports.

Key facts

What you'll do

Oversee the relationship with the CertifyOS vendor, including budget management and contract renewals.

Direct the daily operations of the CertifyOS vendor and ensure they meet service level agreements.

Manage all provider licensing and renewal processes across various states.

Ensure timely submission and tracking of all provider licenses.

Monitor vendor performance against established service level agreements.

Collaborate with internal teams to confirm provider licensing is complete before their start dates.

Identify opportunities to enhance licensing workflows through automation and process improvements.

Maintain precise licensing records and ensure adherence to all state licensing board regulations.

Manage all commercial, Medicaid, and managed Medicaid payer credentialing activities.

Personally oversee provider enrollment, re-credentialing, and payer applications from start to finish.

Track credentialing status and proactively address any enrollment delays.

Ensure providers are credentialed and eligible for billing before patient care delivery whenever possible.

Maintain comprehensive and accurate credentialing documentation.

Monitor re-credentialing schedules to prevent any lapses.

Own payer roster management for all contracted health plans.

Ensure provider roster submissions are accurate, timely, and aligned with payer systems.

Coordinate additions, terminations, demographic changes, tax ID updates, and location changes with contracted payers.

Conduct regular audits of payer rosters to identify and correct any discrepancies.

Work with Revenue Cycle teams to resolve billing issues stemming from roster inaccuracies.

Develop standardized processes for roster maintenance to support organizational growth.

Build and maintain strong relationships with commercial and government payer credentialing representatives.

Lead monthly payer operational meetings to discuss credentialing escalations, enrollment times, roster accuracy, re-credentialing performance, and process improvements.

Serve as the primary point of contact for resolving payer credentialing issues.

Represent the licensing and credentialing function in cross-functional meetings with Contracting, Revenue Cycle, Compliance, Clinical Operations, and Legal.

Collaborate with these teams to resolve payer-related issues impacting provider enrollment.

Support the development of delegated credentialing programs with contracted payers.

Partner with Compliance and Quality teams to ensure delegated credentialing requirements are met.

Coordinate payer audits and maintain audit readiness.

Own and report on key performance metrics such as days to credential, on-time license renewal rate, and payer roster accuracy.

Define the processes, documentation, and workflows for this function to ensure scalability as provider volume, state coverage, and payer relationships grow.

Proactively communicate metric trends and process gaps to leadership.

Requirements

Bachelor's degree or equivalent combination of education and work experience.

A minimum of 5 years of experience in provider licensing and payer credentialing.

Solid understanding of CAQH, NPPES, PECOS, Medicare enrollment, Medicaid enrollment, and commercial payer credentialing processes.

Strong abilities in communication, negotiation, and relationship management.

Excellent problem-solving and escalation management skills.

Capacity to manage multiple priorities while maintaining attention to detail.

Experience leading cross-functional initiatives to improve operational performance.

Experience managing multi-state provider licensing.

Experience managing vendor relationships and delegated credentialing programs.

Experience working with CertifyOS or comparable credentialing software is preferred.

Experience credentialing providers through commercial and Medicaid payers is preferred.

Experience managing payer roster submissions and provider directory accuracy is preferred.

Nice to have

None specified.

Skills & tools

CertifyOS (preferred)

Practical notes

Benefits include medical, dental, vision, long-term disability, life insurance, flexible spending account, and 401k.

12 company holidays, floating holidays, holiday shutdown, flexible time off, and parental leave are provided.

Additional benefits include a health and wellness stipend, home office reimbursement, and professional development reimbursement.

Stock options are available.

Brightline offers a total rewards philosophy that includes fair, equitable, and competitive compensation, which is geo-based and tied to performance and potential. This is informed by market research and internal input.

The annual base salary range for this position is $80,000 - $90,000.

Brightline is committed to building a diverse, equitable, and inclusive workforce.