Director, Provider Enrollment

RESPONSIBILITIES

• Provider Enrollment Management: Provide direct oversight of the full provider enrollment lifecycle, including initial applications, re-credentialing, demographic updates, and terminations. Ensure timely, complete, and accurate submission of provider data to commercial and government payers, clearinghouses, and regulatory bodies.
• Compliance and Regulatory Adherence: Ensure all enrollment activities comply with applicable federal, state, and payer-specific regulations (e.g., CMS, Medicaid, Medicare Advantage, CAQH, PECOS). Maintain awareness of regulatory changes and lead updates to policies, procedures, and workflows to ensure ongoing compliance.
• Team Leadership: Lead, coach, and support a high-performing team of enrollment managers, leads, and specialists. Establish performance goals and productivity benchmarks while fostering a culture of accountability, collaboration, and continuous learning.
• Process Improvement: Design and implement process improvement initiatives to increase accuracy, reduce turnaround times, and enhance automation across enrollment functions. Partner with IT and other stakeholders to evaluate and implement technology solutions that streamline workflows.
• Data Management: Ensure accuracy, consistency, and completeness of provider records in internal databases and enrollment platforms. Maintain the integrity of data across interconnected systems (e.g., AthenaIDX, NPPES, CAQH, credentialing systems).
• Stakeholder Communication: Serve as the primary liaison for internal and external stakeholders regarding provider enrollment and credentialing. Build strong working relationships with payer representatives, regulatory agencies, internal operations, and revenue cycle teams.
• Reporting and Analytics: Develop and deliver routine and ad-hoc reports on provider enrollment status, performance metrics, and payer response timelines. Use data to identify trends, forecast needs, and provide insights to leadership for strategic planning.
• Problem Resolution: Lead the resolution of enrollment-related challenges, including payer denials, rejected applications, and credential discrepancies. Ensure prompt escalation and closure of issues to avoid disruption in claims processing and provider payments.
• Benchmarks: Implement effective strategies to proactively mitigate claim holds related to provider enrollment and credentialing. Drive collaboration with internal departments—including Revenue Cycle, Managed Care, and Payer Relations—to resolve enrollment-related payment delays and denials.
• Target: Ensure that no more than 20% of Provider Enrollment claim holds are over 90 days old, based on the View Age date, monthly.
• New Business Set up: Oversee the timely and accurate setup of payer groups and provider enrollments to support the new site or state expansions. Ensure provider data is in place to enable claim submission and minimize revenue delays for new business lines.

REQUIRED QUALIFICATIONS

• Minimum of 5 years of progressive supervisory or management experience in provider enrollment and credentialing in a healthcare setting.
• Demonstrated ability to develop, implement, and evaluate strategic enrollment initiatives that drive organizational performance.
• An ability to interpret data and enrollment metrics to identify trends, resolve root cause issues, and implement continuous improvements.
• Proven experience working with CMS, DOH, CAQH, PECOS, Medicare, Medicaid, and major commercial payers.
• Strong knowledge of professional billing processes, reimbursement methodologies, payer protocols, and revenue cycle impact of enrollment delays.
• Experience in physician, hospital, and managed care settings related to enrollment and credentialing.
• Exceptional leadership abilities with a track record of motivating, developing, and managing high-performing teams.
• Skilled in conflict resolution, staff development, and maintaining a professional, inclusive, and productive work environment.
• Demonstrated ability to initiate and implement change through cross-functional collaboration and performance improvement.
• Excellent verbal and written communication skills, including presentation and facilitation in both one-on-one and group settings.
• Ability to communicate with clarity, transparency, and professionalism across all levels of the organization.
• Strong follow-up and escalation skills with the ability to resolve complex issues in a timely and collaborative manner.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint).
• Strong understanding of regulatory and accreditation standards, including CMS, NCQA, and Joint Commission guidelines as they relate to credentialing and enrollment.
• Experience building reference libraries, SOPs, and training materials for team and organizational use.
• Strong organizational and decision-making abilities; able to work independently or collaboratively.
• Ability to travel up to 10 to 15% as required.  

PREFERRED QUALIFICATIONS

• Minimum 7-10 years progressive supervisory or management experience in provider enrollment credentialing in a healthcare setting
• Knowledge of NCQA, Joint Commission, and CMS regulatory requirements related to credentialing and enrollment.
• Proficiency in interpreting data, enrollment metrics, and KPIs to identify trends, resolve issues, and support operational improvements.
• Experience with enrollment and credentialing systems such as CAQH ProView, PECOS, NPPES, Availity, or similar platforms.
• Demonstrated success leading teams through change initiatives, system transitions, or workflow redesign.
• Familiarity with EHR or practice management systems (e.g., AthenaIDX, Epic, etc.) preferred.
• Associate or bachelor’s degree preferred
• Power BI reporting experience a plus
• Viso and Project Management tool proficiency is preferred

Total Rewards

• Salary: $105,670.74 – $145,297.26
• Generous benefits package, including:
  • Paid Time Off
  • Health, life, vision, dental, disability, and AD&D insurance
  • Flexible Spending Accounts/Health Savings Accounts
  • 401(k)
  • Leadership and professional development opportunities