Credentialing Manager – PCP & Ancillary Providers

Position Summary

• The Credentialing Lead is a senior healthcare operations leader responsible for provider credentialing, recredentialing, and payer enrollment across a growing medical organization.
• This role owns the end-to-end credentialing lifecycle for physicians and advanced practice providers (APPs) and ensures compliance with NCQA, CMS, state licensing boards, and payer requirements.
• This position focuses on process improvement, compliance, audit readiness, and scalability, ensuring credentialing and enrollment operations support organizational growth without delays or regulatory risk.
• This role is eligible for a performance-based bonus incentive.

Key Responsibilities

Provider Credentialing & Enrollment

• Own the full provider credentialing and recredentialing process for physicians, APPs, and clinical staff
• Manage payer enrollment with commercial, Medicare, and Medicaid plans
• Serve as the credentialing subject-matter expert for regulatory and accreditation requirements
• Maintain credentialing policies, procedures, and documentation standards

Credentialing Operations & Process Improvement

• Evaluate and improve credentialing workflows, cycle times, and handoffs
• Standardize credentialing and enrollment processes to support multi-state growth
• Develop SLAs, checklists, escalation paths, and quality controls
• Partner with HR, Medical Operations, Revenue Cycle, Compliance, Legal, and Contracting

Compliance, Risk Management & Audits

• Ensure compliance with NCQA, CMS, state medical boards, and payer credentialing requirements
• Maintain audit-ready credentialing files and lead internal and external audits
• Identify credentialing and enrollment risks and implement mitigation plans
• Oversee clinician supervisory roster management

Team Leadership & Credentialing Management

• Lead, train, and develop credentialing and enrollment staff
• Establish performance metrics and accountability
• Create documentation and training to reduce operational risk
• Scale credentialing team structure and workflows (Director level)

Reporting & Stakeholder Communication

• Track and report on credentialing KPIs (time to credential, time to enroll, backlog, expirables)
• Provide clear status updates to executive and clinical leadership
• Set realistic credentialing and enrollment timelines with stakeholders

Minimum Qualifications

• 5+ years of experience in provider credentialing and payer enrollment
• Associate’s degree required; Bachelor’s degree in Healthcare Administration, Business, or related field preferred
• Proven experience managing provider credentialing operations in a healthcare or medical group setting
• Strong knowledge of NCQA, CMS, payer enrollment, and state licensing requirements
• Experience leading credentialing teams and improving operational performance
• Strong skills in process design, workflow optimization, and compliance management

Preferred Qualifications

• CPCS, CPMSM, or equivalent credentialing certification
• Experience in healthcare services, medical groups, MSOs, or value-based care organizations
• Experience supporting multi-state provider operations
• Experience implementing or optimizing credentialing software or enrollment platforms