Director of Credentialing

The Director of Credentialing is responsible for leading, managing, and enhancing the organization's credentialing, privileging, provider enrollment, and payer enrollment operations across all clinics and care delivery sites. This role ensures full compliance with regulatory, accreditation, and payer requirements while driving operational excellence, process innovation, and a positive provider experience. The Director oversees credentialing staff, manages key external vendor relationships, maintains exceptional standards of accuracy and timeliness, and serves as the organization's primary expert on credentialing policies, workflows, and industry standards.

Responsibilities

Provide strategic leadership for all credentialing, recredentialing, privileging, and provider enrollment activities; Build, lead, and mentor a high-performing credentialing team; Develop and implement departmental goals, SOPs, KPIs, and quality assurance measures; Facilitate training, ongoing education, and change management; Oversee verification of licensure, education, training, certifications, work history, malpractice coverage, and professional references; Establish proactive workflows for managing expirable items; Ensure accurate management of provider files and credentialing data within credentialing software platforms; Direct the privileging process in collaboration with medical leadership, department chiefs, and compliance teams; Provide credentialing support for committee meetings, audits, board reviews, and documentation needs; Ensure compliance with federal, state, and local regulatory bodies including CMS, The Joint Commission, NCQA, URAC, and commercial payer standards; Maintain up-to-date knowledge of regulatory changes and lead revisions to policies, procedures, and workflows; Conduct and oversee internal audits to ensure readiness for accreditation surveys and external reviews; Oversee timely and accurate submission of enrollment applications with Medicare, Medicaid, and commercial payers; Track and manage enrollments, revalidations, payer updates, and expirables; Partner with Revenue Cycle and Managed Care to resolve enrollment-related claim issues; Manage external credentialing and verification vendors; Evaluate vendor capabilities, negotiate service agreements, and monitor KPIs; Lead transitions, implementations, or optimization projects involving outsourced credentialing or enrollment partners; Continuously evaluate and enhance credentialing workflows; Lead implementation or optimization of credentialing software, automation tools, and data-management technologies; Develop and oversee dashboard reporting for KPIs, productivity, turnaround time, and quality metrics; Collaborate with IT, Managed Care, Compliance, and Operations on cross-functional systems; Serve as the primary organizational contact for providers, clinical leaders, health plans, and regulatory bodies regarding credentialing matters; Promote a provider-centric experience through timely communication and exceptional service standards; Collaborate with HR, Legal, Compliance, Managed Care, and Clinical Operations on onboarding and cross-functional initiatives; Deliver clear presentations to executive leadership, including reporting on credentialing performance, risks, and mitigation strategies; Prepare and present executive-ready materials including slide decks, dashboards, and credentialing summaries

Requirements

Bachelor's degree in healthcare administration, business, or related field; 7 or more years of credentialing experience in a healthcare organization, MSO, medical group, ASC, or hospital; 3 or more years of leadership or management experience; Strong working knowledge of CMS, Joint Commission, NCQA, URAC, and payer credentialing and enrollment requirements; Proficiency with credentialing software systems, provider databases, and digital document management; Experience in multi-site or multi-state healthcare delivery organizations, or MSOs

Nice to have

Master's degree in healthcare administration, business administration, or related field; Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM); Proficiency with CredentialStream/Verity; Experience implementing credentialing software or leading large-scale credentialing process redesign; Exceptional attention to detail and commitment to data accuracy; Strong analytical, organizational, and project management abilities; Excellent written, verbal, and presentation development skills; Ability to lead teams through change and build scalable credentialing infrastructure; High integrity, discretion, and commitment to confidentiality; Ability to work cross-functionally and influence without formal authority; Strong relationship management and customer service orientation