AVP Provider Enrollment Credentialing

WVU Medicine

1d•Onsite

About The Position

The Assistant Vice President (AVP), Provider Enrollment & Credentialing provides strategic and operational leadership for all provider credentialing, privileging, and payer enrollment functions across the health system. This role is accountable for building and sustaining a high-performing, compliant, and scalable infrastructure that ensures providers are credentialed, privileges, and enrolled with government and commercial payers accurately and efficiently to directly protect the organization’s ability to bill, collect, and recognize revenue for provider services. The AVP leads a multi-site or system-level team responsible for primary source verification, medical staff credentialing and reappointment, delegated and non-delegated payer enrollment, CAQH and provider database integrity, and ongoing regulatory compliance with NCQA, CMS, Joint Commission, and state-specific requirements. This individual serves as the organization’s subject matter expert on credentialing and enrollment matters, advising senior executives, Medical Staff leadership, and Payer Relations & Contracting on the operational and compliance implications of growth, Mergers & Acquisitions (M & A), network changes, and payer relationships. This is a highly visible leadership role with significant cross-functional reach, requiring close collaboration with Payer Relations & Contracting, Revenue Cycle, Physician Recruitment, Medical Staff Services, Compliance, Legal, and Finance. The AVP is expected to bring both strategic judgment and hands-on operational expertise to a function with direct, measurable revenue impact.

Requirements

Bachelor’s degree in health care administration or a related field of study or seven (7) years of relevant work experience.
Twelve (12+) years of progressive experience in provider credentialing, medical staff services, and/or payer enrollment, including at least five to eight (5-8) years in a leadership/management capacity.
Demonstrated experience with NCQA, CMS, and Joint Commission standards as they relate to credentialing.
Experience overseeing delegated and non-delegated payer enrollment processes at a payer, multi-facility or system level.
Demonstrated success leading through a Joint Commission or NCQA survey cycle.
Proven people-leadership experience, including managing directors, managers and building team capability.
Working knowledge of credentialing/enrollment platforms (e.g., CAQH, PECOS, NPPES, CredentialStream).

Nice To Haves

Advanced degree in Healthcare Administration (MHA), Business Administration (MBA), or a related field of study preferred.
Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM) through NAMSS
Experience at an academic medical center or large multi-hospital health system ($5B+ net revenue).
Experience supporting M & A integration, consent-to-assign analysis, or large-scale network consolidation from a credentialing/enrollment perspective.
Experience with Physician-Hospital Organization (PHO) governance, delegated credentialing agreements, and PHO-level payer enrollment
Familiarity with revenue cycle metrics and the financial impact of enrollment turnaround time on clean-claim rate and days in A/R
Experience implementing workflow automation within a credentialing/enrollment function.

Responsibilities

Develop and execute the system’s strategy for provider credentialing and payer enrollment, ensuring alignment with organizational growth, M & A activity, and network expansion plans.
Support the VP & Chief Managed Care Officer in department budget, staffing model, and productivity benchmarks; identify and close staffing or workflow gaps relative to best-practice standards.
Lead, develop, and retain multi-tiered team of directors, managers, supervisors, and credentialing/enrollment specialists; build leadership bench strength.
Drive automation and technology adoption to improve scalability, turnaround time, and data accuracy.
Oversee initial credentialing, reappointment, privileging, and Focused/Ongoing Professional Practice Evaluation (FPPE/OPPE) processes in partnership with Medical Staff leadership.
Ensure credentialing files, bylaws, and processes meet NCQA, Joint Commission, CMS, and state regulatory standards; lead survey readiness and serve as a key resource during accreditation surveys.
Maintain delegated credentialing agreements.
Oversee end-to-end payer enrollment operations across Medicare, Medicaid, and commercial payers, including CAQH attestation, NPI/PECOS maintenance, and roster management.
Serve as subject matter expert on payer enrollment matters affecting business development, market expansion, M & A integration, new delegation agreements, consent-to-assign, or contract-novation scenarios.
Minimize revenue leakage from enrollment delays by setting and monitoring turnaround-time targets and escalation pathways.
Oversee credentialing and payer enrollment for providers participating in the system’s Physician-Hospital Organization (PHO), including employed, independent, and affiliated practice participants.
Maintain compliance with PHO governance, bylaws, and participation agreements as they relate to credentialing standards and payer enrollment eligibility.
Serve as the primary point of escalation for PHO-related credentialing or enrollment discrepancies affecting claims submission or payer directory accuracy.
Partner with Payer Relations & Contracting, Revenue Cycle, and Finance to ensure enrollment and credentialing timelines support clean-claim submission and minimize denial/write-off exposure.
Advise the Chief Revenue Cycle Officer, Chief Financial Officers, and other senior executive on credentialing/enrollment risk and readiness related to new service lines, acquisitions, and payer market changes.
Partner with Physician Recruitment to streamline provider onboarding timelines.
Ensure full compliance with HIPAA, False Claims Act, Anti-Kickback Statute, and payer-specific administrative requirements as they relate to provider data and enrollment.
Maintain confidentiality of sensitive provider information in accordance with regulatory and organizational policy.
Oversee vendor relations (CVOs, credentialing software vendors) including contract performance and Service Level Agreement management.
Establish and maintain relationships with payers, HMOs, and other organizations essential to maintaining the PHO network, and conducting CMSO business.