Director-Payor Enrollment and Credentialing

General Summary

Is responsible for the strategic leadership, operational oversight, and regulatory compliance of the centralized credentialing/enrollment and primary source verification operations across the organization. Ensures the effective and efficient verification of provider credentials in alignment with organizational policies, payer requirements and accreditation standards, such as those from NCQA, URAC and The Joint Commission. Serves as a key liaison among hospitals, ambulatory practices, payer relations and executive leadership.

Duties and Responsibilities

Essential Functions:

• Leads and develops a high-performing team of credentialing/enrollment professionals, including managers, specialists and coordinators.
• Collaborates with executive leadership, medical staff services, compliance, legal, payer contracting and HR to ensure cross-functional alignment.
• Ensures compliance with all applicable state and federal regulations, payer requirements and accrediting bodies. Oversees quality control for credentialing/enrollment file completeness, timeliness and accuracy.
• Leads credentialing/enrollment audits and oversees corrective action plans, as needed.
• Develops and monitors key performance indicators (KPI) to track productivity, turnaround times and expirable.
• Drives process improvement initiatives to reduce turnaround time and enhance stakeholder satisfaction.
• Partners with health plans, credentialing/enrollment committees and provider groups to support contracting and enrollment efforts.
• Partners with physician leadership, recruitment, and onboarding teams to ensure a seamless and efficient credentialing/enrollment process.
• Develops and implements credentialing/enrollment strategies aligned with health system growth, mergers, and clinical integration efforts.
• Leads optimalization and utilization of credentialing/enrollment software systems to support scalability and accuracy.
• Recruits, mentors and retains a high-performing credentialing/enrollment team.

Qualifications

Minimum Education:

• Bachelors Degree in Health Care Administration, Business Management, or related field required.

Work Experience:

• 5 years Leadership experience in network credentialing or payer enrollment required.

Licenses:

• Certified Provider Credentialing Specialist Upon Hire Preferred or
• Certified Professional Medical Services Management Upon Hire Preferred

Knowledge, Skills, and Abilities:

• In-depth knowledge of credentialing/enrollment regulations and best practices
• Exceptional leadership, communication and stakeholder management skills
• Analytical and data-driven with strong problem-solving capabilities
• Expertise with credentialing/enrollment software (e.g.; CACTUS, Verity, ECHO, Axuall)
• Ability to lead change and foster a culture of compliance and continuous improvement
• Proficiency in credentialing standards for facilities and health plans, medical terminology and/or business management.
• Ability to effectively utilize Microsoft Office tools (Excel, Word, PowerPoint) and other software tools as required.