Data analytics for performance and quality measures

Data analytics for performance and quality measures

Credentialing Director


Job Title: Credentialing Director   Supervised by: Administrator / COO

Job Summary: The Director is responsible for administering credentialing and provider enrollment
services throughout our nationwide practices. Manages a team of Credentialing Specialists who are
responsible for primary source credentials verification, delegated credentialing and provider
enrollment. Manages and monitors processes and procedures that support credentialing,
re-credentialing, expirables data management and delegated credentialing contract process to ensure
compliance with CAQH standards, state and federal regulations and individual health plan
requirements. The Director will be responsible for credentialing analysis, quality assurance,
planning, client/vendor relationships and continuous improvement of operational performance. Will
work cooperatively with staff, physicians, leadership, department directors and vendors.


Demonstrates Competency in the Following Areas:
Analyze and implement process improvements to enhance efficiency of credentialing Conduct on-going
program evaluations and audits of data integrity.
Ensure accurate outcomes and compliant procedures to meet service goals
Coordinates with practice management, licensing agencies, insurance carriers, and other appropriate
organizations to complete credentialing and re-credentialing applications
Manages staff including interviewing and selecting qualified candidates, coaching for career
development, training, monitor productivity and accuracy, conduct performance evaluations,
guidelines and changes, consistent application of HR policies and procedures, and guide staff to
confident decision-making.

Serve as primary resource to employees with regards to issues, interpretation and application of
organization and department policies and procedures.

Direct the output of a team of employees engaged in credentialing of providers Resolve the most
complex problems related to credentialing.
Support, participate and contribute to the development and growth of credentialing functions
Works with various departments to ensure a smooth transition of providers when on-boarding, for new
contracts and during acquisitions.
Assumes responsibility for own personal continuing education and developmental needs; attends
meetings, workshops to enrich personal knowledge, growth and management skills.

Demonstrates the ability to be flexible, organized and function under stressful situations. Fosters
good public relations for the company and the client.

Professional Requirements:

Adheres to dress code, appearance is neat and clean. Completes annual education requirements.
Maintains regulatory requirements, including all federal, state, local regulations. Maintains and
ensures client confidentiality at all times.
Reports to work on time and as scheduled.
Attends annual review and performs departmental in-services.

Professional Requirements:

Works at maintaining a good rapport and a cooperative working relationship with clients and staff.
Represents the company in a positive and professional manner.
Effectively and consistently communicates administrative directive to staff and encourages
interactive departmental meetings and discussions.

Complies with all organizational policies regarding ethical business practices. Communicates the
mission, ethics and goals of the company.

Regulatory Requirements:

• Minimum of 10 years’ of combined management, credentialing or regulatory affairs
experience, preferably in a managed care or insurance environment. Ability to work with physicians
in a collaborative manner.

• Certified Provider Credentialing Specialist (CPCS) and Certified Professional in
Medical Staff Service Management (CPMSM) is preferred.

• Experience with and knowledge of CAQH and credentialing processes.
• Knowledge of delegated credentialing and verification
• Knowledge of related accreditation and certification requirements
• Knowledge of medical credentialing procedures and standards
• Ability to create, implement, document and audit policies and procedures
• Manage both direct and indirect remote employees and ensures internal controls
are followed
• Ability to effectively prioritize and execute tasks in a high-pressure
• Ability to lead and manage others, strong interpersonal, project management and
mentoring skills

Language Skills:

• Able to communicate effectively in English, both verbally and in writing.
• Excellent communication skills.
• Additional languages preferred.


Basic computer knowledge.
• Demonstrates leadership abilities.

Physical Demands:

• For physical demands of position, including vision, hearing, repetitive motion
and environment, see following description.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential
functions of the position without compromising patient care.


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