Director of Licensing & Credentialing

U.S. Oral Surgery Management•Irving, TX

About The Position

The Director, Provider Credentialing & Licensing Operations ensures USOSM oral surgeons are properly licensed and credentialed with payers, on time and in every state where the organization operates. This leader partners with a credentialing vendor to build processes and workflows, clarify vendor, practice leader, and support center roles, and oversee licensing, credentialing, and compliance. The role helps build USOSM’s delegated credentialing program, including policies and procedures that meet payer and NCQA requirements, while overseeing traditional credentialing and recredentialing. The director sets direction for the function, leads a team of four, manages vendors and tools, and uses reporting to monitor performance. The role establishes and enforces KPIs and SLAs, maintains audit-ready provider records, oversees state licensing and hospital privileges processes, and communicates performance, risks, and recommendations to executives, business partners, surgeons, and practice leaders. The department’s workflows and processes must scale as USOSM adds practices, states, and delegated payers.

Requirements

Bachelor’s degree in healthcare administration, business, or a related field.
At least 8 years of experience in provider credentialing, licensing, or payer enrollment in dental, medical, or another healthcare setting.
At least 5 years of people-management experience.
Experience partnering with an outsourced credentialing vendor to build processes and workflows.
Hands-on experience building or running a delegated credentialing program, including policies, credentialing committee, payer delegation audits, and monthly roster reconciliation.
Basic understanding of state licensing, permit, and compliance requirements, with the ability to research requirements state by state.
Proven experience managing vendors through SLAs, KPIs, and scorecards, and managing a department budget.
Experience designing and documenting workflows, defining team roles, and setting up and managing a ticket-based service process.
Strong reporting experience, including extracting reports and service tickets from credentialing, ticketing, and vendor systems and building KPI dashboards in advanced Excel.
Very strong written and verbal communication skills, including experience presenting to executives.
Self-starter who works well with limited direction.

Nice To Haves

Dental credentialing experience.
Experience with oral and maxillofacial surgery or specialties that credential with both dental and medical plans.
Experience with credentialing and enrollment software, such as CAQH or other tools.
Power BI or similar reporting tools.
Knowledge of credentialing standards such as NCQA and/or credentialing certification such as CPCS or CPMSM.
Experience with ticketing tools such as ServiceNow, Zendesk, or Jira.

Responsibilities

Own the relationship with credentialing vendor partners, including quarterly business reviews, contract performance, and escalations.
Work with vendors to build and refine processes, workflows, handoffs, communication cadence, escalation paths, and performance expectations.
Ensure provider data, payer rosters, and application status are accurate and reconciled between USOSM and the vendor.
Establish KPI and SLA reporting to improve credentialing turnaround time and ensure surgeons are ready to treat patients.
Build, lead, and develop a team of four across licensing, credentialing oversight, compliance, and reporting; manage hiring, performance, and succession planning.
Design and document workflows for surgeon onboarding, licensing, hospital privileges, credentialing, recredentialing, and payer enrollment.
Own the department staffing plan and budget, and scale workflows as the organization grows.
Develop and deliver education and communication materials for executives, business partners, surgeons, the clinical governance board, and practice leaders.
Oversee oral surgeon licensing, including state dental and medical licenses, board certifications, anesthesia and sedation permits, DEA and state controlled-substance registrations, hospital privileges, and required exams.
Maintain state-by-state licensing, permit, and renewal requirements; track expirations and renewals; keep provider files accurate and audit-ready; and escalate compliance risks.
Partner with compliance and legal experts to meet state requirements and regulations, and with practice leaders to ensure new surgeons are licensed and ready to treat.
Build hospital privileges workflows and education materials to support practice leaders’ enrollment processes.
Build and lead USOSM’s delegated credentialing program, including payer-specific workflows, policies, and procedures.
Work with the vendor’s credentialing committee and establish file review standards that meet payer delegation requirements and NCQA standards.
Represent USOSM in payer pre-delegation and annual delegation audits, and conduct regular internal audits of vendor files.
Oversee monthly roster reconciliation and reporting with delegated payers, including additions, terminations, and demographic changes.
Ensure vendor delegated work complies with payer delegation agreements and grow the delegated program with the Director of Payer Strategy where appropriate.
Oversee traditional credentialing and recredentialing with dental and medical payers that are not under delegation; monitor application status, follow-up, and effective dates.
Maintain accurate and current provider data, including CAQH, NPPES, and payer rosters; prioritize payer credentialing based on network decisions from the Director of Payer Strategy.
Establish and manage a ticket-based service process for practice leaders to request help and for the team to track, prioritize, and resolve credentialing or hospital privileges issues.
Oversee the hospital privileges enrollment model, supporting practice leaders who manage hospital enrollments at the practice level.
Develop hospital privileges workflows with standard steps, required documents, timelines, and handoffs; train and guide practice leaders; and resolve escalated issues with hospital medical staff offices.
Monitor privileges status, reappointment dates, and support tickets across practices, and intervene when an issue risks a lapse in privileges.
Manage vendor performance against contract SLAs; conduct regular performance and business reviews; and lead corrective action when performance falls short.
Track KPIs including credentialing turnaround time, backlog, effective dates, approval rates, renewal compliance, delegation audit results, roster reconciliation accuracy, hospital privileges ticket volume and resolution time, and time-to-bill for new surgeons.
Extract reports and service tickets from vendor portals, ticketing systems, and credentialing systems; build and own monthly dashboards and status reports for leadership, practices, and the payer strategy team.
Present function performance, risks, and recommendations to executive leadership.