BACKGROUND

Antidote Health believes healthcare is a basic human right. Our mission is to redefine healthcare by providing affordable, high-quality, accessible care and insurance products. We offer telehealth services in several states and ACA-compliant health insurance plans in Ohio and Arizona, with plans to expand. Our "virtual-first" approach integrates with in-person care and features $0 Antidote virtual provider visits, low to no copay for in-person visits, and $0 medication benefits. If you are an experienced, mission-driven team member who can flex and adapt to the shifting circumstances of a growth-stage startup and are passionate about care quality, lowering healthcare costs, and improving health and financial outcomes for members, Antidote has a great opportunity.

JOB SUMMARY

The Manager of Health Plan Credentialing (Manager) is responsible for overseeing all aspects of provider and practitioner credentialing and recredentialing for Antidote’s health plans. This role ensures compliance with NCQA, CMS, and state regulatory requirements, manages delegated credentialing arrangements, and leads the Credentialing Committee.

The Manager monitors credentialing activities, resolves alerts and special considerations, and collaborates with internal and external stakeholders to maintain a high-quality, compliant provider network. This position directs credentialing operations, supervises staff, and partners with internal and external stake holders to ensure data integrity, compliance, and operational excellence.

KEY RESPONSIBILITIES

• Manage all credentialing and recredentialing processes in compliance with NCQA, CMS, and state regulations, ensuring compliance with required timeframes.
• Manage new licenses and renewals for Antidote’s professional corporation and integrates data with the human resources system.
• Oversee delegated credentialing, including performance monitoring, audits, and compliance assurance.
• Conduct provider outreach to obtain required documentation and resolve credentialing discrepancieswhen required
• Direct the Credentialing Committee, including agenda preparation, taking minutes, documentation review, and coordination with the Chief Medical Officer (CMO).
• Establish and maintain relationships with external CVO partners.
• Audit provider rosters, integrate CAQH data, and ensure accurate, up-to-date provider records.
• Supervise credentialing staff, provide leadership, training, and performance management.
• Collaborate with provider relations, contracting, data, and quality teams to support provider onboarding, network integrity and provider data accuracy.
• Develop, review, and update credentialing policies and procedures annually.
• Prepare and present reports on credentialing metrics, audit results, and compliance status to senior leadership and quality committees.
• Respond to internal and external audits and regulatory reviews.
• Lead process improvement initiatives to streamline credentialing operations and enhance provider experience.
• Leverage credentialing platform and reporting tools to enhance operational efficiency.

QUALIFICATIONS

The requirements listed below represent the necessary knowledge, skills, and abilities. Reasonable accommodations can be made to enable individuals with disabilities to perform the essential functions.

• Bachelor’s degree in healthcare administration, business or related field preferred; equivalent combination of education and experience considered.
• Current CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Services Management) from NAMSS (National Association of Medical Staff Services).
• Minimum of 5 years of experience in health plan credentialing, including 2+ years in a supervisory role.
• Experience with delegation oversight, Credentialing Committee management, and NCQA credentialing standards.
• Familiarity with CAQH data systems and credentialing software.
• Strong analytical, organization and communication skills.

SKILLS AND COMPENTENCIES

• Comprehensive understanding of NCQA, CMS and state regulatory bodies.
• Ability to interpret and apply accrediting standards and regulatory requirements to the credentialing process.
• Familiarity with primary source verification, provider enrollment, audit preparation and interpretation of audit findings.
• Ability to develop, implement, and revise credentialing policies and procedures.
• Conducts internal and external audits and prepares for accreditation surveys.
• Prepares corrective action plans and monitors compliance metrics.
• Ensures activities are conducted in accordance with accreditation and payer requirements.
• Serves as the subject matter expert in the design and development for credentialing dashboards and databases.
• Supervises credentialing staff, provides training, mentoring and performance evaluations.
• Builds a collaborative and accountable team culture.
• Serves as liaison with contracted provider organizations’ credentialing teams.
• Presents cases to Credentialing Committee and senior leadership.
• Uses KPIs to identify inefficiencies and implements streamlined workflows.
• Resolves discrepancies in provider documentation and credentialing issues.

WORK ENVIRONMENT

• Hybrid position requiring periodic on-site presence at Antidote’s office.
• Must have a quiet, distraction-free workspace to perform duties effectively from home.
• Work location must be secure and private to maintain HIPAA compliance.
• This position may require travel.