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Director, Credentialing
Posted 3 days agoViewed
💎 Seniority level: Director, 10+ years
💸 Salary: 164900.0 - 214450.0 USD per year
🔍 Industry: Healthcare
🏢 Company: Spring Health👥 1001-5000💰 $100,000,000 Series E 8 months agoMental HealthArtificial Intelligence (AI)mHealthWellnessHealth Care
🗣️ Languages: English
⏳ Experience: 10+ years
Requirements:
- 10+ years of experience in healthcare credentialing, compliance, and provider network management, preferably within a health plan or managed care setting.
- Proven leadership experience managing credentialing teams of 10+ individuals and scaling operations to support business growth.
- Deep knowledge of NCQA accreditation standards and experience preparing for and leading regulatory site surveys (NCQA, TJC, CMS, etc.).
- Ability to define and drive execution at scale—you understand what right looks like and can build a clear, actionable roadmap to achieve credentialing and compliance goals.
- Strong process improvement skills, with experience implementing credentialing technology and workflow automation.
- Experience in payer relations and delegated credentialing, with a track record of navigating audits and compliance requirements.
- Exceptional analytical and problem-solving skills, with the ability to leverage data to drive operational decisions.
- Strong collaboration and stakeholder management skills, working cross-functionally with internal teams and external payers.
- Excellent communication skills, with the ability to articulate complex compliance and credentialing concepts clearly.
- Commitment to fostering a high-performance culture, with an emphasis on continuous learning and operational excellence.
Responsibilities:
- Oversee all aspects of the credentialing/recredentialing of practitioners in alignment with State, Federal, and NCQA standards, as well as contracted health plan directives, including pre-delegation and annual audits of all credentialing delegated entities.
- Build and oversee Payer enrollment processes, including the submission, tracking, and follow-up of applications, to ensure timely and accurate enrollment of providers with Medicare, Medicaid, and managed care programs. This will require developing efficient, scalable workflows from the ground up.
- Manage and ensure quality related to credentialing operations, providing oversight to support the continued growth and development of the organization.
- Work cross-functionally with Product, Health Plan Operations, Medical Affairs, and Compliance teams to pull and analyze reports, ensuring that credentialing data aligns with organizational goals and regulatory standards.
- Act as the Subject Matter Expert (SME) for credentialing processes and systems, providing guidance and support to internal stakeholders to ensure compliance and efficiency.
- Establish, implement, and monitor performance goals, metrics, and processes for the Credentialing department. Prepare and maintain various reports, data, and summaries of credentialing activities.
- Lead the implementation of new credentialing tools and systems to enhance operational efficiency and compliance.
- Maintain familiarity with network adequacy and provider network standards to ensure compliance with regulatory and contractual requirements.
- Manage provider data by conducting regular audits to ensure the accuracy and integrity of provider information in credentialing databases and systems, collaborating with data management teams to develop and implement data quality initiatives, automate data entry processes, and resolve discrepancies efficiently.
- Collaborate closely with the Revenue Cycle Management (RCM) team to ensure that provider credentialing and enrollment statuses are up-to-date, facilitating successful claims processing and reimbursement.
- Provide strong leadership and development opportunities to the credentialing team, fostering a collaborative and high-performance culture.
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