Director, Credentialing and Enrollment

Strategic Roadmap: 

• Define and execute the long-term vision for credentialing and enrollment, transitioning from manual processes to a tech-enabled, scalable operation.

• Team Leadership: 

  • Lead and mentor the Credentialing & Enrollment team. 

  • Foster a culture of extreme detail-orientation and accountability.

  • Payer Enrollment & Strategy: 

    • Oversee the end-to-end enrollment process for Medicare, Medicaid, and Commercial payers. 

    • Be the primary liaison for enterprise contract activations, ensuring our network meets specific payer density and licensing/credentialing requirements.

    • Credentialing

      • Oversee initial credentialing and re-credentialing applications for registered dietitians.

      • Conduct ongoing monitoring of licensure, certifications, and sanctions via state licensing boards and exclusion lists, certification entities, OIG List of Excluded Individuals/Entities (LEIE), National Practitioner Data Bank (NPDB), and System for Award Management (SAM) database.

      • Maintain and update provider licensing, credentials, and insurance records in the credentialing database system

      • Track license and certification expirations for medical staff to ensure timely renewals

      • Delegated Credentialing: 

        • Own and manage delegated credentialing agreements. 

        • Lead all audit activities to ensure 100% compliance with NCQA, state Medicaid, and CMS standards.

        • Cross-Functional Quarterback: 

          • Act as the operational bridge between Sales (new client launches), Clinical Quality and Operations (provider performance), and RCM (denial management related to enrollment).

          • Data-Driven Optimization: 

            • Leverage data to identify bottlenecks in the licensing/enrollment funnel. 

            • Use Excel/Sheets to track KPIs such as "Days to Enroll" and "Credentialing Pass Rates." 

            • Leverage AI for process improvement and automation.

            • Compliance & Committee: 

              • Lead the internal Credentialing Committee, presenting provider files and ensuring all primary source verifications (NPDB, OIG, SAM) are flawless.

              • Ensure compliance with applicable laws, regulations, procedures, and policies

              • Maintain knowledge of current credentialing requirements and best practices (e.g., NCQA standards)

Experience: 7+ years in healthcare operations, with at least 3+ years specifically in a leadership role overseeing Credentialing and Payer Enrollment.

Telehealth Expertise: Proven track record of managing multi-state licensure and enrollment for a distributed provider network.

Regulatory Mastery: Deep knowledge of NCQA standards, CMS (Medicare/Medicaid) regulations, and the "alphabet soup" of the industry (CAQH, PECOS, NPPES, NPI).

Technical Proficiency: Intermediate to advanced skills in Excel/Google Sheets and experience with credentialing software (e.g., Medallion).

Education: Bachelor’s degree required; CPCS, NAMSS or CPMSM certification is a significant plus.

Demonstrated ability to manage complex projects and meet deadlines

Excellent organizational and time management skills

Exceptional verbal and written communication skills

Ability to work independently and as part of a team

High level of accuracy and attention to detail