Healthcare Operations Manager

Job Summary:

This role oversees end-to-end healthcare operations with a special focus on navigating complex state and federal regulations and managing provider credentialing for both private and government payers. The ideal candidate ensures organizational compliance while streamlining credentialing processes to support provider network integrity and financial reimbursement.

Key Responsibilities:
Regulatory Oversight & Compliance:

• Stay abreast of federal and state healthcare laws and regulations including HIPAA, HITECH, False Claims Act, EMTALA, and others as applicable.
• Develop, update, and enforce compliance policies, standard operating procedures, and internal controls to meet regulatory requirements.
• Oversee internal monitoring, audits, investigations, and corrective action plans to address compliance risks.
• Serve as the organization’s liaison to regulatory bodies and manage site visits or inquiries from oversight agencies.

Provider Credentialing & Enrollment Management:

• Lead all credentialing functions for providers seeking participation with private insurers as well as Medicare, Medicaid, and other government payers.
• Oversee primary source verification of credentials—licensure, education, training, board certifications, malpractice history, and NPDB checks.
• Ensure structured review of credentials through internal committees, and manage approval workflows for clinical privileges and payer panel access.
• Ensure consistent re-credentialing, license renewals, and data accuracy in the credentialing database, maintaining alerts and timely updates.

Operations Leadership & Process Optimization:

• Develop efficient credentialing workflows and systems to reduce provider onboarding turnaround time.
• Coordinate across departments—clinical, billing, compliance, legal—to ensure credentialing aligns with revenue cycle and compliance goals.
• Manage vendor relationships for credentialing software or third-party verification services.
• Implement accreditation standards (e.g., EHNAC) where relevant to credentialing operations.

Training, Audit & Reporting:

• Train team members on regulatory updates, credentialing best practices, and documentation standards.
• Conduct regular audits to identify gaps in credentialing or compliance processes and implement corrective actions.
• Provide periodic reporting to leadership on credentialing timelines, compliance issues, regulatory changes, and audit findings.

Team & Stakeholder Management:

• Supervise credentialing specialists, compliance analysts, and operations support staff.
• Collaborate with compliance, legal, finance, and clinical departments to align credentialing operations with strategic and regulatory priorities.
• Foster continuous improvement and a culture of compliance awareness across the organization.

Qualifications:

Education & Experience:

• Bachelor’s degree in Health Administration, Healthcare Management, Nursing, Public Health, or related field; Master's degree (MHA, MPH, or MBA) preferred.
• Minimum 5 years of progressive experience in healthcare operations, provider credentialing, and/or compliance management.
• Proven track record managing credentialing for both private and government payers.

Regulatory & Technical Expertise:

• Deep understanding of healthcare regulatory landscape including HIPAA, HITECH, Stark Law, False Claims Act, EMTALA, and CMS credentialing guidelines.
• Experienced in primary source credentialing, NPDB querying, accreditation standards (e.g., EHNAC).
• Proficient with credentialing platforms, provider enrollment systems, and compliance tracking tools.

Certifications (Highly Preferred):

• Certified in Healthcare Compliance (CHC), Certified Professional Compliance Officer (CPCO), or similar certifications.

Leadership & Soft Skills:

• Excellent organizational, project management, and analytical skills.
• Strong leadership and team-building capabilities.
• Effective communicator with the ability to influence stakeholders across departments.
• High ethical standards, discretion, and sound judgment in sensitive regulatory environments.