Director of Credentialing
il y a 7 jours
Austin
Job DescriptionDescriptionThe Director of Credentialing provides strategic leadership and oversight for provider credentialing, payer enrollment and maintenance, professional liability administration, regulatory compliance, and credentialing readiness across Aspire Allergy & Sinus. This leader develops and implements the processes, service standards, technology, reporting, and team structure needed to support our growing, multi-state specialty healthcare organization. The Director leads the Credentialing Manager and credentialing team while collaborating closely with Revenue Cycle Management, Payer Contracting, Human Resources, Talent Acquisition, Legal and Compliance, Operations, Clinical Leadership, Information Technology, Finance, providers, payers, and external partners. This role is essential to protecting patient access and organizational revenue by ensuring providers are credentialed and enrolled accurately and efficiently. The Director ensures complete provider records, verified payer effective dates, accurate system configuration, appropriate professional liability coverage, and audit-ready documentation. This position requires full-time onsite work at our HQ location at 5929 Balcones Dr, Austin, TX 78731. Key ResponsibilitiesEssential Functions:• Develop and maintain the enterprise credentialing strategy, operating model, policies, procedures, staffing plan, service standards, controls, training, and annual priorities.• Define responsibilities, decision rights, handoffs, and escalation paths across the Director, Manager, and Specialist levels and all cross-functional partners.• Oversee initial credentialing, recredentialing, primary-source verification, licensure, education and training, work history, references, board certification, DEA and controlled-substance registrations, and other required qualifications.• Ensure providers are appropriately credentialed, appointed, enrolled, revalidated, and, when applicable, privileged with health plans, hospitals, and patient care facilities under approved policies and applicable requirements.• Direct enrollment and maintenance for Medicare, Medicaid and managed Medicaid, commercial payers, Medicare Advantage, TRICARE or VA networks, and other contracted programs.• Oversee group and individual enrollment, reassignment, roster submission, revalidation, demographic maintenance, location and entity additions, EFT and ERA setup, ownership disclosures, and documented effective-date confirmation.• Ensure applications and system records reflect the correct provider, group NPI, TIN, legal entity, service location, taxonomy, specialty, participation status, and billing relationships.• Maintain governance over CAQH, NPPES, PECOS, state Medicaid systems, payer portals, credentialing platforms, provider master data, and supporting documentation.• Establish complete, current, signed, secure, and audit-ready provider files, including documentation of discrepancies, exceptions, approvals, and corrective action.• Oversee exclusion, sanction, licensure, and adverse-action monitoring through applicable federal, state, payer, and licensing sources, including OIG LEIE, SAM, NPDB processes where authorized, and state licensing boards.• Lead delegated credentialing readiness and ongoing compliance, including file audits, committee materials, corrective-action plans, reporting, and payer or accreditation reviews where applicable.• Own the administrative process for professional liability coverage in partnership with Finance, Legal, Human Resources, insurance brokers, carriers, and providers.• Maintain accurate provider and entity insurance schedules, certificates of insurance, limits, policy periods, retroactive dates, coverage changes, claims-history documentation, and required evidence of coverage.• Coordinate malpractice coverage changes for new hires, terminations, leaves, acquisitions, locum tenens, contractors, new entities, and locations; escalate gaps, tail requirements, claims, and legal interpretations.• Partner with Revenue Cycle Management and Operations to prevent and resolve credentialing-related denials, nonparticipating claims, missed effective dates, invalid billing relationships, and avoidable patient-access disruption.• Establish a closed-loop process to identify, quantify, resolve, and trend denials and underpayments caused by credentialing, enrollment, roster, demographic, location, or effective-date issues.• Reconcile provider, payer, location, entity, taxonomy, and participation data across credentialing systems, the EHR and practice management platform, clearinghouse, payer directories, scheduling tools, and financial reporting.• Approve credentialing readiness gates for new providers and locations and ensure scheduling or billing releases are supported by verified effective dates or documented executive exceptions.• Lead credentialing workstreams for acquisitions, changes of ownership, new markets, de novo clinics, relocations, legal-entity changes, service-line launches, and provider transitions.• Develop diligence requests, provider and payer inventories, risk assessments, dependency maps, workplans, cutover criteria, and post-close remediation plans for growth initiatives.• Recruit, develop, coach, and retain a high-performing team with measurable expectations, quality standards, cross-training, succession plans, and reliable backup coverage.• Direct workload, aging, follow-up cadence, quality reviews, performance management, and escalation practices through the Credentialing Manager and team leads.• Own the functional roadmap for credentialing technology, workflow automation, payer portal access, document management, reporting, data standards, and system integration.• Maintain executive dashboards for provider readiness, payer status, effective dates, aging, rosters, revalidations, expirables, malpractice, audit findings, denials, and acquisition milestones.• Provide timely executive reporting on performance, barriers, at-risk revenue, compliance exposure, resource needs, corrective actions, and strategic priorities.• Perform other duties and lead special projects consistent with the scope and leadership level of the position. Performance Measures:• At least 95% of providers meet the approved credentialing readiness gate by the planned start date, excluding documented external payer or provider delays.• At least 95% of complete applications are submitted within the approved internal service standard.• All scheduling and billing releases include documented payer effective-date evidence or an approved exception.• No preventable lapse in a license, DEA registration, malpractice policy, or other critical credential.• At least 98% of revalidations and roster requirements are completed by the internal due date, with exceptions actively escalated.• At least 95% internal file-audit pass rate with timely correction of all material findings.• Sustained reduction in credentialing-related denials, at-risk revenue, queue aging, and repeat root causes.• Growth and acquisition credentialing milestones are completed against approved workplans with risks documented and escalated. Skills, Knowledge & ExpertiseCompetencies:• Enterprise leadership that connects credentialing priorities to patient access, revenue, compliance, provider experience, and growth.• In-depth knowledge of provider credentialing, payer enrollment, primary-source verification, professional liability administration, and applicable federal and state requirements.• Strong operational discipline, including process design, controls, documentation, workload management, quality assurance, and continuous improvement.• Demonstrated ability to lead teams, develop managers and specialists, establish accountability, and manage through organizational change.• Highly analytical and detail oriented, with the ability to quantify business exposure and distinguish controllable performance from payer-controlled timelines.• Strong interpersonal, written, and oral communication skills with the ability to influence executives, providers, payers, vendors, and cross-functional partners.• Sound judgment, integrity, discretion, and the ability to maintain confidentiality of privileged and sensitive information at all times.• Flexible, proactive, technology-oriented, and able to prioritize competing deadlines in a fast-paced, multi-state environment. Physical demands/requirements:• Prolonged periods of sitting, viewing a computer monitor, participating in meetings, and using a telephone or videoconferencing platform.• Manual dexterity sufficient to operate a computer, keyboard, calculator, telephone, copier, and other standard office equipment.• Ability to occasionally handle and lift materials weighing up to 20 pounds.• Reasonable accommodations may be made to enable qualified individuals with disabilities to perform essential functions. Required Education and Experience:• Bachelor’s degree in healthcare administration, business, finance, management, or a related field; equivalent relevant experience may be considered.• Seven or more years of progressive experience in provider credentialing, payer enrollment, medical staff services, or healthcare administration, including at least three years leading people or a major function.• Demonstrated experience supporting a multi-site, multi-state physician organization, health system, management services organization, or comparable healthcare enterprise.• Working knowledge of Medicare, Medicaid and managed Medicaid, commercial payer enrollment, CAQH, PECOS, NPPES, NPDB processes, exclusion screening, revalidation, reassignment, rosters, EFT and ERA, and payer portals.• Experience establishing service levels, dashboards, quality audits, standard operating procedures, compliance controls, and executive reporting. Preferred Education and Experience:• Certified Provider Credentialing Specialist, Certified Professional Medical Services Management, or comparable professional credential.• Experience with allergy, ENT, ambulatory specialty practices, or private-equity-backed healthcare organizations.• Experience with delegated credentialing, NCQA or URAC-aligned standards, payer audits, or accreditation readiness.• Experience leading credentialing integration for acquisitions, changes of ownership, new legal entities, or de novo locations.• Experience with credentialing platforms, EHR or practice management systems, data visualization, workflow automation, and structured process improvement. Travel:Periodic travel to clinics, payer meetings, acquisitions, audits, and leadership events is required, generally up to 15%. Job Benefits • Eligibility for an annual performance-based incentive, • Medical, Dental and Vision Insurance, • Life Insurance, • Mileage Reimbursement, • Generous Paid Time Off and Paid Holidays, • 401(k) + Generous Employer Match, • Treatment Discounts, • Reward Program, • ...AND MORE!
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