Job Description:
• Provide strategic and operational leadership over provider credentialing, re-credentialing, and payer enrollment functions for diverse healthcare clients.
• Develop and execute the strategic vision for credentialing and enrollment service delivery, aligning operations with company growth targets and client expectations.
• Serve as the senior point of escalation for client concerns related to credentialing and enrollment timelines, quality, and outcomes.
• Oversee the end-to-end credentialing lifecycle, including initial credentialing, re-credentialing, and privileging support for all provider types.
• Ensure compliance with NCQA, URAC, CMS, Joint Commission, and state-specific credentialing standards and regulations.
• Monitor and manage expirables tracking and ensure timely renewal of licenses, certifications, and other time-sensitive documents.
• Direct all payer enrollment, re-enrollment, and revalidation activities across commercial, Medicare, Medicaid, and managed care payers.
• Recruit, train, mentor, and manage a team of credentialing specialists and enrollment coordinators.
• Drive continuous process improvement initiatives using Lean, Six Sigma, or similar methodologies.
• Lead the strategic initiative to achieve and maintain NCQA Credentials Verification Organization (CVO) certification for the company.
Requirements:
• Bachelor's degree in Healthcare Administration, Business Administration, or a related field.
• 5–7+ years of progressive experience in provider credentialing and payer enrollment, including management-level responsibility.
• Demonstrated experience managing credentialing/enrollment operations in a vendor, outsourcing, or multi-client environment.
• Deep working knowledge of NCQA credentialing standards, CMS enrollment regulations, and CAQH/PECOS/NPPES systems.
• Proven ability to manage and develop teams of 10+ credentialing and enrollment professionals.
• Strong understanding of the provider revenue cycle and the downstream impact of credentialing and enrollment delays.
• Proficiency with credentialing software platforms and Microsoft Office Suite.
• CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Services Management) certification through NAMSS (preferred).
• Master's degree in Healthcare Administration (MHA), Business Administration (MBA), or related discipline (preferred).
• Experience with delegated credentialing arrangements and payer delegation audits (preferred).
• Familiarity with Lean/Six Sigma process improvement methodologies (preferred).
• Experience supporting multi-state, multi-specialty provider organizations (preferred).
• Knowledge of telehealth credentialing and interstate licensure compact requirements (preferred).
Benefits:
• Business Travel: Required - 0-50% depending on the month