Credentialing Lead - Onsite

Credentialing Lead

Position Summary

The Credentialing Lead is responsible for overseeing and
executing complex provider credentialing activities across multiple states and
payer networks. This role serves as the subject matter expert for escalated
credentialing issues, ensures regulatory and accreditation compliance, manages
provider credential expirations, and drives operational excellence within the
credentialing function. The Credentialing Lead owns the credentialing work
queue, prioritizes high-risk and time-sensitive cases, and partners closely
with providers, payers, licensing boards, and internal stakeholders to ensure
timely enrollment and ongoing compliance.

Key Responsibilities

Credentialing Operations

• Manage
  and maintain ownership of the credentialing and recredentialing work
  queue, ensuring timely processing and resolution of cases.
  
• Handle
  complex credentialing scenarios, including multi-state licensure, payer
  enrollment challenges, provider relocations, and high-priority onboarding
  cases.
  
• Coordinate
  and submit credentialing applications to commercial, government, and
  managed care payers.
  
• Monitor
  credentialing status and proactively address delays, deficiencies, or
  barriers to enrollment.
  

Escalation Management

• Serve
  as the primary escalation point for credentialing-related issues.
  
• Investigate
  and resolve complex credentialing and enrollment problems with payers,
  providers, and regulatory agencies.
  
• Develop
  corrective action plans and drive issues through resolution while
  maintaining stakeholder communication.
  

Expiration & Compliance Management

• Oversee
  tracking and management of provider licenses, certifications,
  registrations, malpractice insurance, and other credentialing
  requirements.
  
• Ensure
  timely renewals and prevent lapses that could impact provider eligibility
  or reimbursement.
  
• Maintain
  accurate credentialing records and documentation in credentialing systems
  and databases.
  

Accreditation & Quality Oversight

• Maintain
  credentialing processes in accordance with accreditation standards.
  
• Support
  audits, accreditation reviews, and internal quality assurance initiatives.
  
• Ensure
  credentialing policies, procedures, and documentation remain compliant
  with regulatory and accreditation requirements.
  
• Identify
  process improvement opportunities and implement best practices to
  strengthen compliance and operational efficiency.
  

Leadership & Collaboration

• Provide
  guidance and mentorship to credentialing specialists and team members.
  
• Establish
  and monitor credentialing performance metrics, service levels, and quality
  standards.
  
• Collaborate
  with Provider Operations, Compliance, Revenue Cycle, Clinical Leadership,
  and external partners to support organizational goals.
  
• Assist
  in developing workflows, training materials, and standard operating
  procedures.
  

Qualifications

Required

• 3+
  years of provider credentialing experience, including payer enrollment and
  recredentialing.
  
• Demonstrated
  experience managing complex credentialing cases and multi-state provider
  credentials.
  
• Strong
  understanding of credentialing regulations, payer requirements, and
  provider enrollment processes.
  
• Experience
  working with credentialing software, CAQH, NPPES, PECOS, and state
  licensing boards.
  
• Knowledge
  of accreditation standards such as NCQA, URAC, or Joint Commission.
  
• Excellent
  organizational, problem-solving, and communication skills.
  
• Ability
  to manage multiple priorities in a fast-paced environment.
  

Preferred

• Certified
  Provider Credentialing Specialist (CPCS) certification.
  
• Experience
  leading credentialing operations or serving as a team lead.
  
• Experience
  supporting multi-state healthcare organizations.
  
• Advanced
  reporting and process improvement experience.
  

Success Measures

• Credentialing
  and enrollment turnaround times meet or exceed organizational goals.
  
• Provider
  credential expirations are proactively managed with minimal to no lapses.
  
• Escalated
  credentialing issues are resolved efficiently and effectively.
  
• Accreditation
  and audit requirements are consistently met.
  
• Credentialing
  queue remains current and within established service level agreements.
  
• High
  levels of provider and internal stakeholder satisfaction.
  

Requirements

Education

• High school diploma or GED required
  
• Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or related field preferred
  

Experience

• 3+ years of provider credentialing or medical staff services experience preferred
  
• Experience with payer enrollment and provider credentialing processes
  
• Knowledge of commercial, Medicare, and Medicaid enrollment requirements
  
• Experience working in a healthcare organization, provider network, or health plan preferred
  

Required Knowledge

• Provider credentialing and re-credentialing processes
  
• Primary Source Verification (PSV)
  
• CAQH ProView maintenance
  
• NPI and PECOS enrollment
  
• Medicare, Medicaid, and commercial payer enrollment
  
• NCQA, CMS, Joint Commission, and state regulatory requirements
  
• Provider file maintenance and document management
  
• Medical terminology and healthcare operations
  

Technical Skills

• Microsoft Office (Excel, Word, Outlook)
  
• Credentialing software 
  
• Electronic document management systems
  
• Database management and accurate data entry
  
• Internet research and state licensing board websites
  

Core Competencies

• Exceptional attention to detail
  
• Strong organizational skills
  
• Time management and prioritization
  
• Excellent written and verbal communication
  
• Customer service orientation
  
• Problem-solving and critical thinking
  
• Ability to manage multiple deadlines
  
• Ability to work independently and collaboratively
  
• Confidentiality and professionalism
  

Benefits