Credentialing and Regulatory Operations Manager

Overview

The Credentialing and Regulatory Operations Manager oversees provider credentialing, licensing, privileging, and physician supervision to ensure compliance with federal, state, regulatory, accreditation, and payer requirements. This role leads credentialing operations, manages staff and workflows, oversees the supervising physician program, and ensures timely and accurate processing of provider credentials to support organizational and patient care needs.

Responsibilities

Credentialing & Licensing Operations

• Own end-to-end strategy and execution of provider credentialing, re-credentialing, supervising physician management, privileging, and licensing at scale
• Ensure compliance with CMS, NCQA, Joint Commission, state licensing boards, and payer-specific requirements
• Oversee primary source verification including education, training, licensure, board certification, DEA, sanctions, and work history, with clear quality controls
• Oversee the ongoing maintenance of supervising/collaborating physician relationships and agreements
• Serve as primary liaison with providers, supervising physicians, clinical leadership, regulatory agencies, and internal departments
• Partner with Compliance, Legal, Revenue Cycle, Provider Operations, and Clinical Leadership to align credentialing timelines with onboarding, payer enrollment, and go-live readiness
• Coordinate credentialing information required for payer enrollment, revalidation, and re-credentialing

Regulatory & Quality Assurance

• Develop, implement, and maintain credentialing policies, procedures, and workflows
• Conduct internal audits to ensure accuracy, completeness, and regulatory compliance
• Prepare for and participate in accreditation surveys, audits, and regulatory reviews
• Stay current on changes in credentialing regulations, accreditation standards, and payer requirements
• Maintain accurate supervising physician agreements and related documentation

Leadership & Team Management

• Lead, coach, and develop direct reports, setting clear performance expectations and quality standards
• Design and optimize team workflows to improve turnaround times, scalability, and accuracy
• Serve as a subject matter expert and escalation point for complex credentialing and supervising physician operational issues
• Promptly escalate credentialing, licensing, supervision, or compliance risks to appropriate leadership

Systems & Reporting

• Own credentialing systems and tooling (e.g., Modio, Symplr, Helix or similar), ensuring data integrity and audit readiness
• Proactively manage credentialing cycles, expirations, and renewals to prevent provider downtime
• Define and monitor key operational metrics (turnaround times, aging, compliance gaps, provider readiness)
• Develop and maintain dashboards, reports, and tracking mechanisms for credentialing status, expiration dates, outstanding documentation, and compliance risks
• Produce insights and reporting that inform leadership decisions, capacity planning, and process improvements

Requirements

• Bachelor’s degree in healthcare administration, business administration, or related field (or equivalent experience)
• 3+ years of progressive experience in provider credentialing, licensing, or medical staff services
• 2+ years of supervisory or management experience
• In-depth knowledge of credentialing standards (NCQA, Joint Commission, CMS)
• Strong understanding of provider credentialing, privileging, and licensing requirements
• Strong leadership and team management skills
• Exceptional attention to detail and organizational abilities
• Ability to interpret complex regulations and apply them operationally
• Excellent written and verbal communication skills
• Proficiency in credentialing software and Google applications
• Ability to manage multiple priorities and meet deadlines in a fast-paced environment

Preferred Qualifications

• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM)
• Experience with multi-state licensing and large provider networks
• Degree in healthcare administration or related field

Compensation & Benefits

Pay Bands By Tier

• Tier 1 (San Francisco and similar cost markets): $103,770 - $115,300 base salary
• Tier 2 (Chicago and similar cost markets): $82,980 - $92,200 base salary
• Tier 3 (National, all other U.S. locations): $72,630 - $80,700 base salary

Benefits

Specific benefits vary by country and location of employment. During the interview process, a recruiter will confirm the exact package available.

• Paid Time Off: Flexible vacation, sick leave, and 12 statutory holidays
• Health & Insurance: Medical, Dental, Vision, Disability, and Life insurance
• Wellness: Mental health programs and an Employee Assistance Program (EAP)
• Retirement: RRSP/401(k) program with company match
• Development: Annual reimbursement for eligible training and professional programs

Location

This role is for a U.S.-based organization; care is provided exclusively to patients in the United States. The team is distributed across the United States and Canada.

Applicants must be legally authorized to work in the country where the role is based at the time of application.