Director of Credentialing

Key Responsibilities

• Provide strategic leadership for all credentialing, recredentialing, privileging, and provider enrollment activities.
• Build, lead, and mentor a high-performing credentialing team with appropriate staffing, training, accountability, and performance management.
• Develop and implement departmental goals, SOPs, KPIs, and quality assurance measures.
• Facilitate training, ongoing education, and change management as credentialing systems and requirements evolve.

Credentialing and Privileging Operations

• Oversee verification of licensure, education, training, certifications, work history, malpractice coverage, and professional references.
• Establish proactive workflows for managing all expirable items, including license, certification, and insurance renewals.
• Accurately manage provider files, credentialing data, and documentation 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.

Regulatory Compliance

• Ensure compliance with all 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 accordingly.
• Conduct and oversee internal audits to ensure readiness for accreditation surveys and external reviews.

Provider Enrollment

• Oversee timely and accurate submission of enrollment applications with Medicare, Medicaid, and commercial payers.
• Track and manage enrollments, revalidations, payer updates, and expirables to prevent reimbursement delays or claim denials.
• Partner with Revenue Cycle and Managed Care to resolve enrollment-related claim issues and streamline payer setup workflows.

Vendor Relationship Management

• Manage external credentialing and verification vendors, ensuring high performance, compliance, service quality, and contractual adherence.
• Evaluate vendor capabilities, negotiate service agreements, monitor KPIs, and drive accountability for accuracy and turnaround times.
• Lead transitions, implementations, or optimization projects involving outsourced credentialing or enrollment partners.

Process Improvement and Technology

• Continuously evaluate and enhance credentialing workflows to reduce turnaround times, improve accuracy, and support scalability.
• Lead implementation or optimization of credentialing software, automation tools, and data-management technologies.
• Develop and oversee dashboard reporting for KPIs, productivity, turnaround time, expirables, enrollment status, and quality metrics.
• Collaborate with IT, Managed Care, Compliance, and Operations on cross-functional systems and technology initiatives.

Relationship and Communication Management

• 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, streamlined processes, and exceptional service standards.
• Collaborate with HR, Legal, Compliance, Managed Care, and Clinical Operations on onboarding and cross-functional initiatives.
• Deliver clear, concise 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 for operational and leadership reviews.