Director of Credentialing - Business Process Management

About this role

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…