Director, Credentialing & Provider Enrollment

The Director of Credentialing is responsible for leading, managing, and enhancing the organization’s credentialing, privileging, provider enrollment, and payer enrollment operations across all clinics and care delivery sites. This role ensures full compliance with regulatory, accreditation, and payer requirements while driving operational excellence, process innovation, and a positive provider experience.

The Director oversees credentialing staff, manages key external vendor relationships, maintains exceptional standards of accuracy and timeliness, and serves as the organization’s primary expert on credentialing policies, workflows, and industry standards.



Key Responsibilities

Leadership and Management

• 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.

• 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.
• Ensure accurate management of 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.

• 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.

• 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.

• 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.

• 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.

• Serve as the primary organizational contact for providers, clinical leaders, health plans, and regulatory bodies regarding credentialing matters.
• Promote a provider-centric experience…