Director of Credentialing

---

Job description

Overview:
The Director of Credentialing is responsible for overseeing all aspects of provider credentialing-including physicians, facilities, and ancillary services-ensuring compliance with NCQA, the Texas Department of Insurance (TDI), and CMS requirements. This leadership role involves managing the entire credentialing process, maintaining a comprehensive provider database, and coordinating with various departments to ensure timely and accurate uploads of provider information to the claims system, data search tools, and website provider directories.

The ideal candidate must have extensive knowledge of credentialing software systems and conversions, with preference given to experience with HealthStream (formerly Verity). The Director will also supervise credentialing staff and manage relationships with external credentialing clients. In addition, the candidate must have significant experience with delegated credentialing processes and oversight, including managing facility applications, delegated agreements, and conducting thorough reviews of provider groups' policies and procedures in accordance with current NCQA standards and delegated entity performance.

Responsibilities:
Oversee all aspects of provider credentialing (physicians, facilities, and ancillary services), ensuring full compliance with NCQA, TDI, and CMS requirements.

Manage the credentialing process from initial application through final approval, ensuring timely and accurate verification of provider qualifications.

Manage the recredentialing process through final approval, ensuring timely and accurate verification of provider qualifications in full compliance with NCQA.

Provide expertise in hospital credentialing, including managing the privileging processes and collaborating with medical staff offices.

Manage the oversight process for all delegated credentialing agreements to ensure final approval is consistent with accurate verification of provider qualifications and NCQA criteria.

Supervise and lead credentialing staff, ensuring efficient and accurate completion of credentialing tasks.

Maintain and update the provider database, coordinating closely with IT and claims departments for accurate data uploads to claims systems, provider directories, and data search tools.

Ensure seamless integration and functionality of credentialing software systems.

Lead software conversions and system upgrades as necessary, ensuring minimal disruptions to credentialing operations.

Collaborate with external credentialing clients to provide verification services, maintaining high-quality standards and satisfaction.

Stay abreast of changes in credentialing standards, regulations, and best practices, adapting processes as needed.

In-depth knowledge of regulatory and accreditation standards, (e.g., NCQA, URAC, Joint Commission) and experience in implementing these within credentialing programs.

Develop and implement policies and procedures to ensure continuous compliance and operational efficiency.

Prepare reports and presentations for the CEO and executive team on credentialing performance and compliance.

Serve as a subject matter expert on credentialing software, processes, and regulations.

Qualifications:
EDUCATION

Completion of a high school diploma or equivalent required.Higher degree accepted.

Bachelors degree in Health Administration, MBA, Health Information Management preferred.

WORK EXPERIENCE:

5 years minimum of experience in provider credentialing, with a strong understanding of NCQA, TDI, and CMS requirements required.

Minimum of 3 years of experience in a management position required.

Proven experience managing credentialing staff and overseeing credentialing processes in a healthcare setting preferred.

<!– job description page –>