Director of Credentialing - Business Process Management

Director of Credentialing & Enrollment Services

Department: Credentialing & Enrollment Operations

Reports To: Vice President of Operations / Chief Operating Officer FLSA Status:

Exempt Location: Remote / Hybrid

Business Travel: Required - 0-50% depending on the month

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Position Summary

The Director of Credentialing & Enrollment Services provides strategic and operational leadership over all provider credentialing, re-credentialing, and payer enrollment functions for a diverse portfolio of healthcare clients. This role is responsible for building scalable processes, maintaining regulatory compliance, driving client satisfaction, and leading a high-performing team that delivers timely, accurate credentialing and enrollment services on behalf of hospitals, physician groups, health systems, and other healthcare organizations.

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Essential Duties & Responsibilities

Strategic Leadership & Client Management

· 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.

· Lead client onboarding, including discovery of payer mix, provider roster assessment, and development of customized enrollment strategies.

· Build and maintain strong relationships with key client stakeholders, including practice managers, revenue cycle leaders, medical staff offices, and C-suite executives.

· Identify opportunities to expand service offerings and drive revenue growth within existing and prospective client accounts.

Credentialing Operations

· Oversee the end-to-end credentialing lifecycle, including initial credentialing, re-credentialing, and privileging support for all provider types (MDs, DOs, NPs, PAs, CRNAs, psychologists, therapists, etc.).

· Ensure compliance with NCQA, URAC, CMS, Joint Commission, and state-specific credentialing standards and regulations.

· Maintain and enforce primary source verification (PSV) protocols, including education, training, licensure, DEA/CDS, board certification, malpractice history, work history, sanctions, and OIG/SAM exclusion monitoring.

· Manage credentialing committee preparation, file presentation, and documentation in accordance with client bylaws and accreditation standards.

· Monitor and manage expirables tracking and ensure timely renewal of licenses, certifications, and other time-sensitive documents.

Payer Enrollment Operations

· Direct all payer enrollment, re-enrollment, and revalidation activities across commercial, Medicare, Medicaid, and managed care payers.

· Oversee the preparation and submission of CAQH, PECOS, NPPES, and state Medicaid portal applications.

· Manage provider roster additions, terminations, demographic updates, and group/location linkages across all payer networks.

· Track and resolve enrollment application denials, delays, and payer-specific issues to minimize revenue cycle disruption for clients.

· Maintain current knowledge of payer-specific enrollment requirements, delegated credentialing agreements, and regulatory changes.

Team Leadership & Development

· Recruit, train, mentor, and manage a team of credentialing specialists, enrollment coordinators, and team leads.

· Lead and coordinate a geographically distributed, global workforce across multiple continents (e.g., North America, Asia, and other offshore/nearshore locations), ensuring seamless collaboration, consistent quality standards, and operational continuity across time zones.

· Develop and implement communication protocols, shift-overlap strategies, and cross-cultural management practices to maximize the productivity and engagement of international teams.

· Establish and monitor individual and team performance metrics, including turnaround times, accuracy rates, and client satisfaction scores, with standardized KPIs applied uniformly across all global locations.

· Conduct regular one-on-one meetings, performance reviews, and professional development planning, adapting leadership approaches to the cultural and regulatory context of each region.

· Foster a culture of accountability, continuous improvement, and operational excellence across all sites.

· Manage staffing levels and workload distribution across onshore, nearshore, and offshore teams to meet client SLAs and contractual obligations while optimizing cost efficiency.

Process Improvement & Technology

· Drive continuous process improvement initiatives using Lean, Six Sigma, or similar methodologies.

· Collaborate with product and engineering teams to continuously improve and enhance the organization’s proprietary, in-house credentialing software platform, providing subject matter expertise on workflow requirements, user needs, feature prioritization, and regulatory-driven enhancements.

· Develop and maintain standard operating procedures (SOPs), workflows, and training documentation.

· Leverage data analytics and reporting to identify trends, bottlenecks, and opportunities for operational improvement.

· Evaluate and recommend new technologies, automation tools, and integrations to enhance efficiency and scalability.

Compliance & Quality Assurance

· Lead the strategic initiative to achieve and maintain NCQA Credentials Verification Organization (CVO) certification for the company, including gap analysis, policy development, documentation preparation, and management of the full application and survey process.

· Ensure organizational compliance with all applicable federal, state, and accreditation body requirements.

· Lead internal audit and quality assurance programs, including file review, accuracy audits, and corrective action plans.

· Prepare for and support external audits by clients, payers, and accreditation organizations.

· Maintain up-to-date knowledge of regulatory changes affecting credentialing and enrollment (CMS rules, No Surprises Act implications, state mandates, etc.).

· Serve as the subject matter expert on credentialing and enrollment compliance for internal and external stakeholders.

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Qualifications Required

· 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.

Preferred

· CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Services Management) certification through NAMSS.

· Master’s degree in Healthcare Administration (MHA), Business Administration (MBA), or related discipline.

· Experience with delegated credentialing arrangements and payer delegation audits.

· Familiarity with Lean/Six Sigma process improvement methodologies.

· Experience supporting multi-state, multi-specialty provider organizations.

· Knowledge of telehealth credentialing and interstate licensure compact requirements.

Competencies

· Operational Excellence — Drives efficient, scalable processes that deliver consistent, high-quality results across a diverse client portfolio.

· Client-Centric Mindset — Anticipates client needs, communicates proactively, and treats every provider’s enrollment as a revenue-critical priority.

· Regulatory Acumen — Maintains expert-level knowledge of the credentialing and enrollment regulatory landscape and translates requirements into actionable processes.

· People Leadership — Inspires, develops, and retains top talent while fostering a collaborative, high-accountability team culture.

· Problem Solving & Escalation Management — Navigates complex payer issues, client concerns, and operational challenges with composure and resourcefulness.

· Data-Driven Decision Making — Uses metrics, dashboards, and analytics to monitor performance, identify risks, and drive continuous improvement.

· Change Management — Leads teams through technology implementations, process redesigns, and organizational growth with clarity and confidence.