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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.
  

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

• 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
  

• 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
  

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

• 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