Director, Credentialing (Director I)

Director, Credentialing (Director I)

CalOptima

CalOptima Health is seeking a highly motivated an experienced Director, Credentialing (Director I) to join our team. The Director of Credentialing will be responsible for overseeing the process of verifying and maintaining health care provider credentials, ensuring compliance with all relevant regulations and standards, overseeing a contracted credentialing verifications organization (CVO), managing a team of credentialing staff, and ensuring ongoing monitoring of the provider network. The incumbent will be responsible for the development and implementation of quality improvement programs and activities related to provider credentialing to ensure compliance with current policies, procedures and regulatory credentialing standards, which is critical to ensure member care and safety at CalOptima Health. The incumbent will develop and implement policies and procedures to streamline the credentialing workflow within CalOptima Health.

Position Information:

Department: QI - Credentialing
Salary Grade: 320 - $170,772 - $273,234 ($82.10 - $131.3625)
Work Arrangement: Partial Telework

**This position is eligible for telework in California.**

Duties & Responsibilities:

60% - Leadership Functions

Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.
Manages and oversees team members, including assigning and evaluating work, making recommendations on hiring, training and setting goals, conducting performance evaluations and recommending and implementing corrective actions up to and including termination.
Collaborates with leadership and across departments to ensure the successful launch of key CalOptima Health initiatives and to ensure the initiatives function successfully within the CalOptima Health environment.
Develops and implements comprehensive credentialing policies and procedures, ensuring compliance with state and federal regulations, National Committee for Quality Assurance (NCQA) standards, Council for Affordable Quality Healthcare (CAQH) standards and contractual requirements.
Monitors and reports on key credentialing metrics to leadership.
Manages through developing and growing capabilities of the workforce, leading day-to-day operations and monitoring annual project budgets.
Interfaces with all provider related departments to identify, implement and evaluate quality improvement for credentialing activities.
Establishes and maintains a quality assurance process to ensure accuracy of the credentialing data and system.
Develops key performance indicators for ongoing quality monitoring and reporting.
Reports credentialing activities and performance to internal and external stakeholders, including the Credentialing and Peer Review Committee (CPRC), Quality Improvement Committee (QIC) and other committees working on quality improvement activities.
Acts as a liaison or directs appropriately qualified staff to act as liaisons with health networks, physician medical groups, ancillary providers and facilities regarding credentialing.

35% - Program Oversight

Oversees functions of the CVO to ensure accurate and timely credentialing of network providers.
Monitors and evaluates the effectiveness of credentialing processes, identifying areas for improvement and implementing changes.
Conducts regular credentialing audits to identify potential issues and ensure compliance with regulatory standards.
Oversees staffing model, budget plan and monitoring of resource allocation for the team.

5% - Other

Completes other projects and duties as assigned.

Minimum Qualifications:

Bachelor's degree in health care administration, business or a related field PLUS 7 years of management experience overseeing a credentialing team and complex projects; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

Have access to means of transportation for work away from the primary office approximately 10% of the time.

Preferred Qualifications:

Certified Provider Credentialing Specialist (CPCS) certification.

Required Licensure / Certifications:

n/a

Knowledge & Abilities:

Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
Work independently and exercise sound judgment.
Communicate clearly and concisely, both orally and in writing.
Work a flexible schedule; available to participate in evening and weekend events.
Organize, be analytical, problem-solve and possess project management skills.
Work in a fast-paced environment and in an efficient manner.
Manage multiple projects and identify opportunities for internal and external collaboration.
Motivate and lead multi-program teams and external committees/coalitions.
Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Physical Requirements (With or Without Accommodations):

Ability to visually read information from computer screens, forms and other printed materials and information.
Ability to speak (enunciate) clearly in conversation and general communication.
Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Work Environment:

If located at the 500, 505 Building or a remote work location:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
There are no harmful environmental conditions present for this job.
The noise level in this work environment is usually moderate.

If located at PACE:

Work is typically indoors in a clinical setting serving the frail and elderly.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.

If located in the Community:

Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
Employee will occasionally work outdoors in varied temperatures.
There may be harmful or hazardous environmental conditions present for this job.
The noise level in this work environment is usually moderate to loud.

About CalOptima Health:
CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!

About our Benefits & Wellness options:
At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the alliantbenefits.cld.bz/25caloptimacabenguide regarding our comprehensive benefits and wellness package.

IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS

Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is May 14, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.

Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

To apply, please visit: apptrkr.com/6168333

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