CREDENTIALING/ENROLLMENT MANAGER - FULL TIME EXEMPT

About the role

The Credentialing and Enrollment Manager is responsible for overseeing the daily operations of the Credentialing & Enrollment Department under the general supervision of the Director. This role ensures compliance with regulatory standards (NCQA, AAAHC, TJC), and payer standards. The Manager provides leadership, training, and quality oversight to staff, while collaborating with various departments to enhance provider onboarding and management. The position plays a critical role in maintaining accurate documentation, facilitating privileging & committee processes, and supporting the strategic goals of the department and organization.

Responsibilities

• Credentialing & Re-credentialing
  • Primary liaison for credentialing and recredentialing processes for the OHWC Lakeland Highlands Hospital.
  • Securing start dates and coordinating any necessary or requested onboarding tasks, and expense tracking
  • Manage the end-to-end credentialing and re-credentialing process for physicians, nurse practitioners, physician assistants, allied practice professionals, and extenders
  • Verify primary source credentials, including licenses, DEA certificates, education, board certification, work history, and malpractice history; Identify red flags or discrepancies in applications and escalate them to leadership. Including monitoring, tracking, and reporting.
  • Oversee the workflow and productivity of the Credentialing & Enrollment Department, ensuring alignment with organizational goals and policies and procedures.
  • Monitor and maintain compliance with internal standards and external regulatory/accreditation requirements.
• Privileging
  • Create, draft, and implement comprehensive clinical privileges forms, criteria, and dockets tailored specifically to the clinic (outpatient) and Ambulatory Surgery Center (ASC) environments.
  • Research, define, and establish competency metrics for core and specialized procedures
  • Collaborate with Director, Department Chairs, Medical Directors, and the Credentialing Committee to regularly update and refine the delineation of privileges.
  • Develop specialized criteria and clinical checklists to assess and verify ongoing provider competency during re-privileging cycles.
  • Ensure all clinical privileges align with state licensing boards, scope of practice guidelines, and policies
  • Coordinate peer references, competency assessments, and delineation of privileges requests for review by department chairs and the Credentialing Committee.
• Payer Enrollment (Payer Credentialing)
  • Manage provider enrollment with commercial insurance plans, Medicare, Medicaid, and managed care organizations.
  • Ensure timely submission of CAQH profiles, NPPES updates, and payer-specific applications to prevent billing delays and revenue disruption.
  • Maintain an accurate database of provider numbers, effective dates, and contract statuses.
  • Oversee day-to-day network provider enrollment across group and individual submissions, ensuring timely, accurate, and compliant applications tracked in the department’s contracted, web-based, electronic solution
• Compliance & Quality Control
  • Maintain compliance with regulatory bodies such as The Joint Commission, NCQA, CMS, and state-specific healthcare regulations.
  • Conduct regular internal audits of credentialing files and privileging lists.
  • Oversee the maintenance of the credentialing software database and ensure secure document storage.
  • Ens