Director of Credentialing

American Family Care•Birmingham, AL

About The Position

The Director of Credentialing leads and enhances the organization’s credentialing, privileging, provider enrollment, and payer enrollment operations across clinics and care delivery sites. The role ensures compliance with regulatory, accreditation, and payer requirements while advancing operational excellence, process improvement, and a positive provider experience. The Director oversees credentialing staff and external vendor relationships, maintains high standards for accuracy and timeliness, and serves as the organization’s primary expert on credentialing policies, workflows, and industry standards. The Director provides strategic leadership for credentialing and enrollment operations, including team development, departmental goals, standard operating procedures, performance measures, training, and quality assurance. The role oversees verification and maintenance of provider credentials and files, directs privileging in collaboration with medical leadership and compliance teams, and supports committees, audits, and board reviews. The position ensures regulatory readiness and compliance, oversees timely payer enrollment and revalidation, and partners with Revenue Cycle and Managed Care to address enrollment-related claim issues. It manages vendor performance and agreements, leads credentialing technology and process improvement initiatives, and develops reporting on operational and quality metrics. The Director also serves as a primary contact for providers and other stakeholders, collaborates across departments, and presents credentialing performance, risks, and mitigation strategies to executive leadership.

Requirements

Bachelor’s degree in healthcare administration, business, or a related field.
At least 7 years of credentialing experience in a healthcare organization, MSO, medical group, ASC, or hospital.
At least 3 years of leadership or management experience.
Strong working knowledge of CMS, The Joint Commission, NCQA, URAC, and payer credentialing and enrollment requirements.
Proficiency with credentialing software systems, provider databases, and digital document management.
Experience in multi-site or multi-state healthcare delivery organizations, or MSOs.
Exceptional attention to detail and commitment to data accuracy.
Strong analytical, organizational, and project management abilities.
Excellent written, verbal, and presentation development skills.
Ability to lead teams through change and build scalable credentialing infrastructure.
High integrity, discretion, and commitment to confidentiality.
Ability to work cross-functionally and influence without formal authority.
Strong relationship management and customer service orientation.

Nice To Haves

Master’s degree in healthcare administration, business administration, or a related field.
Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) certification.
Proficiency with CredentialStream/Verity.
Experience implementing credentialing software or leading large-scale credentialing process redesign.

Responsibilities

Provide strategic leadership for credentialing, recredentialing, privileging, and provider enrollment activities.
Build, lead, and mentor the credentialing team, including staffing, training, accountability, and performance management.
Develop departmental goals, standard operating procedures, key performance indicators, and quality assurance measures.
Facilitate training, ongoing education, and change management as credentialing systems and requirements evolve.
Oversee verification of provider licensure, education, training, certifications, work history, malpractice coverage, and professional references.
Establish workflows to manage expirable items, including license, certification, and insurance renewals.
Ensure accurate management of provider files, credentialing data, and documentation in credentialing software platforms.
Direct the privileging process in collaboration with medical leadership, department chiefs, and compliance teams.
Provide credentialing support for committee meetings, audits, board reviews, and documentation needs.
Ensure compliance with federal, state, and local regulatory bodies and payer standards, including CMS, The Joint Commission, NCQA, and URAC.
Monitor regulatory changes and lead related revisions to policies, procedures, and workflows.
Conduct and oversee internal audits to ensure readiness for accreditation surveys and external reviews.
Oversee timely and accurate enrollment applications with Medicare, Medicaid, and commercial payers.
Track enrollments, revalidations, payer updates, and expirables to prevent reimbursement delays or claim denials.
Partner with Revenue Cycle and Managed Care to resolve enrollment-related claim issues and streamline payer setup workflows.
Manage credentialing and verification vendors, monitoring performance, compliance, service quality, contractual adherence, accuracy, and turnaround times.
Evaluate vendor capabilities, negotiate service agreements, and lead transitions, implementations, or optimization projects involving outsourced partners.
Improve credentialing workflows to reduce turnaround times, improve accuracy, and support scalability.
Lead implementation or optimization of credentialing software, automation tools, and data-management technologies.
Develop and oversee dashboard reporting on KPIs, productivity, turnaround times, expirables, enrollment status, and quality metrics.
Collaborate with IT, Managed Care, Compliance, and Operations on cross-functional systems and technology initiatives.
Serve as the primary organizational contact for providers, clinical leaders, health plans, and regulatory bodies on credentialing matters.
Promote a provider-centric experience through timely communication, streamlined processes, and high service standards.
Collaborate with HR, Legal, Compliance, Managed Care, and Clinical Operations on onboarding and cross-functional initiatives.
Present credentialing performance, risks, and mitigation strategies to executive leadership.
Prepare and present executive-ready slide decks, dashboards, and credentialing summaries for operational and leadership reviews.