Medical Insurance Credentialing Lead

Job Summary

The Medical Insurance Credentialing Lead will design, launch, and lead the organization’s new credentialing and payer enrollment function. This role involves building workflows, managing payer enrollments, ensuring compliance, and developing a scalable service offering. Additionally, this individual will establish processes, tools, and quality standards and will hire and oversee a Credentialing Assistant as volume grows.

Key Responsibilities

• Design and implement the organization’s credentialing and re-credentialing program from the ground up.

• Develop credentialing workflows, tracking tools, turnaround standards, and standard operating procedures (SOPs).

• Partner with leadership to support the launch of credentialing as a formal internal and external service offering.

• Establish scalable processes to support future growth, new practices, and expanded service demand.

• Manage the full lifecycle of provider credentialing and re-credentialing for physicians and advanced practice providers.

• Prepare, submit, track, and follow up on enrollment applications with Medicare, Medicaid, and commercial payers.

• Maintain complete, accurate, and compliant provider credentialing files, including licenses, certifications, malpractice insurance, and payer documentation.

• Ensure timely updates and attestations in CAQH ProView, PECOS, NPPES, and payer-specific portals.

• Track credentialing timelines, expirations, and renewals to prevent billing delays or network participation gaps.

• Serve as the primary credentialing resource and escalation point for internal teams and external physician partners.

• Hire, train, and supervise a Credentialing Assistant as volume increases.

• Create reporting and metrics related to credentialing turnaround times, payer approval rates, and revenue impact.

• Collaborate with billing and RCM teams to ensure credentialing status aligns seamlessly with claims workflows.

• Support new provider onboarding, practice start-ups, expansions, and network participation optimization.

• Monitor payer policy changes and Florida-specific regulatory updates, recommending and implementing process improvements.

• Contribute credentialing expertise to overall revenue optimization and compliance initiatives.

Qualifications & Preferences

• 4+ years of progressive medical insurance credentialing experience.

• Demonstrated success managing Medicare, Medicaid, and major commercial payer enrollments.

• Strong working knowledge of CAQH ProView, PECOS, NPPES, and payer enrollment platforms.

• Experience managing multiple providers and practices concurrently.

• Exceptional organizational skills and attention to detail.

• Strong written and verbal communication skills with payers, providers, and internal stakeholders.

• Ability to work independently and take ownership of building new operational functions.

• Prior experience launching or formalizing credentialing workflows or programs.

• Bachelor’s degree in Healthcare Administration, Business, or related field.

• CPCS or CPMSM certification strongly preferred.

• Prior experience training or supervising credentialing staff.

• Knowledge of Florida healthcare and payer regulations.

What We Offer

• Competitive compensation with leadership and growth opportunity.

• Comprehensive benefits package including medical, dental, vision, 401(k) with company match, and paid time off.

• Flexible hybrid or remote work options.

• Professional development support, including certification reimbursement.

• Opportunity to build and lead a critical new service line from the ground up.

• A collaborative culture focused on accountability, quality, and continuous improvement.