Provider Qualifications Supervisor - RN

Description

Central Coast Salary Range:  $104,340 - $156,510

Job Summary

The Provider Qualifications Supervisor is responsible for overseeing the daily operations of CenCal Health’s credentialing, facility site review, and medical record review functions. This position combines the oversight of credentialing activities, staff leadership, and delegation management with the execution of Facility Site Reviews and Medical Record Reviews to ensure quality and compliance with local, state, and federal requirements. This position works under the supervision of the Provider Credentialing and Data Integrity Manager.

1. Oversee the daily operations of both the credentialing and Quality Management teams, ensuring that all credentialing and site review and medical record review activities are carried out efficiently and in compliance with regulatory standards.
2. Provide team supervision, leadership and development.
3. Drive quality improvement and process optimization for credentialing and site review functions.
4. Other duties as assigned.

Duties & Responsibilities

1.  Oversee the daily operations of both the Credentialing and Quality Management teams, ensuring that all credentialing and site review and medical record review activities are carried out efficiently and in compliance with regulatory standards.

• Oversee the credentialing, facility site review, and medical record review queues, ensuring that priorities are adjusted based on workload volume, deadlines, and competing tasks to maintain efficiency and meet service level agreements (SLAs).
• Supervise the processing of credentialing and re-credentialing applications for providers, ensuring compliance with NCQA and DHCS standards. Monitor timelines and ensure that applications are processed in a timely manner.
• Ensure the completion of various site reviews—including Full Scope Reviews, Medical Record Reviews (MRR), Specialty Site Reviews, Physical Accessibility Review Surveys (PARS), Focused Reviews, and Interim Onsite Reviews—in accordance with regulatory guidelines and deadlines.
• Ensure that Corrective Action Plans (CAPs) are issued and implemented in response to deficiencies identified during credentialing or site review audits. Provide support for on-site visits, particularly for high-membership physicians, to promote quality care improvements and service delivery.
• Oversee the scheduling and execution of on-site visits, including those for high-membership physicians, and provide educational support to enhance care quality and service delivery.
• Act as back up to conduct facility site reviews and medical record reviews.
• Monitor Compliance with Policies and Procedures through creation and maintenance of credentialing and FSR/MRR policies, workflows, and Standard Operating Procedures (SOPs) to ensure they are up-to-date and compliant with all applicable regulatory standards.
• Ensure accurate and thorough documentation of all credentialing activities, site visit findings, and corrective actions in the appropriate files and systems.
• Participate in internal and external audits, ensuring that findings are addressed, corrective actions are implemented, and compliance is maintained. Monitor and evaluate credentialing metrics, productivity reports, and audit outcomes to ensure that standards and regulatory requirements are consistently met.
• Oversee the delegated credentialing process for delegated provider groups, ensuring that these entities adhere to the required documentation and quality standards.
• Maintain clear and consistent communication with internal teams, external stakeholders, and providers to ensure all credentialing and site review requirements are met, and issues are promptly addressed.
• Stay up to date with industry best practices, regulatory changes, and compliance requirements related to credentialing, site reviews, and provider quality management to ensure CenCal Health remains compliant.  

2.  Provide team supervision, leadership and development.

• Provide guidance, coaching, and support to the credentialing and quality management team.
• Ensure all staff members are properly trained and adhere to service delivery standards and regulatory requirements.
• Monitor staff performance, providing regular feedback and conducting annual evaluations to assess productivity, accuracy, and compliance. Address performance issues promptly to ensure continuous improvement and high-quality service.
• Identify training needs and create a comprehensive development plan for staff to ensure ongoing education and cross-training across key functions.
• Implement training opportunities to enhance team flexibility and capabilities.
• Promote a positive and supportive work atmosphere that encourages collaboration, innovation, and continuous improvement.
• Foster teamwork and a culture of excellence to ensure high-quality service delivery.
• Act as a resource for challenging credentialing and site review cases, offering solutions and guidance for complex provider applications, site visits, and audit findings.

3.  Drive quality improvement and process optimization for credentialing and site review functions.

• Promote a culture of continuous improvement within the credentialing and quality management team.
• Continuously evaluate the credentialing, FSR, and MRR processes to identify areas for improvement.
• Adjust processes as needed to align with the organization's goals and regulatory changes.
• Implement strategies to streamline workflows, increase efficiency, and reduce cycle times, while maintaining compliance with all regulatory requirements.
• Act as a liaison between the credentialing, FSR, and other internal departments to communicate quality improvement opportunities, share insights, and address concerns identified during site visits and credentialing activities.
• Use metrics and performance data to track the effectiveness of process improvements and ensure adherence to service standards. Adjust processes as needed to align with the organization's goals and regulatory changes.
• Represent the credentialing and FSR teams in internal committees, including CenCal Health’s Provider Credentialing Committee, quality committees and workgroups.
• Oversee the quality of materials presented at credentialing meetings, ensuring agendas, supporting documents, and minutes are prepared timely and accurately
• Participate in or lead special projects as assigned by the Provider Credentialing and Data Integrity Manager or other leadership. This may include initiatives related to policy updates, process enhancements, or compliance-related activities.

4.  Other duties as assigned.

Qualifications

Knowledge/Skills/Abilities

Required:

• Proven leadership skills including motivating staff and performance management.
• Able to multi-task in a fast-paced environment, managing multiple priorities and meeting deadlines Strong time management and organizational skills.
• Able to use good judgement in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.
• Able to process a high volume of work and assume special projects over and above assigned responsibilities.
• Strong leadership, organizational, and communication skills. Ability to manage multiple priorities, meet deadlines, and ensure compliance with regulatory requirements. Excellent problem-solving skills for resolving complex credentialing and site review issues.
• Proficiency in Microsoft Office, virtual platforms, credentialing software.

Education & Experience

• Current Registered Nurse (RN) license required, with clinical experience preferred for overseeing medical record reviews and site assessments.
• Three (3) years of experience in a health care setting, with a minimum of 1-2 years in a supervisory or leadership role, or other combination of education and experience that may be qualifying.
• Familiarity NCQA, DHCS, and other regulatory standards related to credentialing, facility site reviews, medical record reviews, and quality management processes.
• Experience with credentialing, facility site review, or medical record view preferred.
• Familiarity with credentialing and quality management software systems, as well as Microsoft Office Suite preferred.
• CPCS strongly desired OR achievement of certification within 24 months.

Salary : $104,340 - $156,510