Director of Credentialing & Payor Enrollment

CarePoint Health•Hoboken, NJ

1d•$130,000 - $175,000

About The Position

Hudson Regional Health is a newly unified healthcare network serving Hudson County through four hospitals. Together, these hospitals form a single, integrated system with a shared vision—to deliver modern, patient-first care supported by innovation. From robotic-assisted surgery and AI-powered diagnostics to real-time monitoring and precision neurosurgery, HRH is redefining what’s possible in community healthcare. Patients across the region now have access to state-of-the-art procedures and nationally recognized specialists, all within a connected, local network designed to put care first. Our Services We focus on the care our patients need most, delivered with precision, innovation, and a commitment to excellence. Advanced Emergency Services - 24/7 emergency departments across all four hospitals Robotic-Assisted Surgery - featuring the Da Vinci XI and ExcelsiusGPS systems Neurosurgery & Spine Care - including Stealth Navigation and precision-guided treatment Women’s Health & Maternity -comprehensive services tailored for every stage Imaging & Diagnostics - AI-enhanced systems for faster, more accurate results Outpatient & Specialty Care - coordinated care across multiple disciplines Our Hospitals Explore our hospitals and discover care that’s high-tech, high-touch, and close to home: Secaucus University Hospital, Flagship campus featuring the Robotic Surgery Institute and modernized emergency care. Bayonne University Hospital, A full-service community hospital offering personalized acute care. Hoboken University Hospital, A local leader in women’s health, family medicine, and outpatient services. The Heights University Hospital (Jersey City), Expanding access to state-of-the-art care in the heart of Jersey City.

Requirements

Bachelor’s Degree or equivalent professional experience in Healthcare
CPMSM and/or CPCS Certification
Five or more years in healthcare managed care contracting experience
Working knowledge of both Managed Care and Provider Insurance Credentialing
Working knowledge of government and non-government insurance, payer requirements, and healthcare operations
Excellent knowledge of healthcare revenue cycle, healthcare finance, CMS and state regulations and healthcare compliance requirements/activities

Responsibilities

Responsible for all aspects of the verification process for medical staff
Develops and implements policies and protocols related to physician, nurse and other employee verifications
Ensures that the organization and staff are in accordance with all standards
Resolving escalated issues within the department
Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion with time periods specified
Leads, coordinates and monitors the review and analysis of practitioner applications and accompanying documents ensuring applicant eligibility
Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures resolution
Administer credentialing audits and conducts internal file audits
Monitors the initial, reappointment and expirable process for all medical staff, Allied Health Professional staff, other health professional staff and delegated providers
Ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, Federal and State) as well as medical staff Bylaws, Rules and Regulations
Develop and trains staff on regulations, policies and procedures
Responsible for the regular review of internal processes in order to evaluate quality and efficiency within the Managed Care Department; recommend, administer and implement multiple activities in support of the Managed Care Department initiatives.
Work with Managed Care Leadership to find efficiencies that will improve processes and communication.
As a working supervisor, research and respond to routine, non-routine, complex and escalated inquiries in a timely and professional manner.
Work with various departments to prevent issues as well as resolve elevated billing, reimbursement, health plan participation and credentialing issues.
Maintain awareness of Payor Managed Care activities for changes in policies, authorization requirements and other processes that impact the Practice.
Maintain the Payor matrix, including limited network participation, to ensure information is accurate and up to date.
Maintain standard operating processes and procedures for contract monitoring and renewals.
Gather current data and monitors changes on plan membership, patient volume, plan/benefit structure, reimbursement and other information needed to complete the contract profile.
Review fee schedules for accuracy and identifies significant changes in reimbursement.
Oversee activities responsible for ensuring that all Providers are credentialed with Payors and Hospitals in a timely and accurate fashion.
Promptly communicate credentialing status to applicable parties.
Monitor Payor directories to ensure all providers are listed accurately by plan
Monitor trends to avoid minor issues from having a major impact on reimbursement and collections.
Other duties as assigned.