Director of Credentialing and Enrollment Services

BASIC FUNCTION

The Director of Credentialing and Enrollment Services oversees and manages all aspects of healthcare clinic, provider and clinical staff credentialing, payer enrollment, patient benefit eligibility and compliance. This role ensures seamless integration of credentialing and eligibility and processes, adherence to regulatory requirements, and optimization of organizational workflows. Additionally, this position provides leadership, supervision, and process improvement initiatives to foster excellence in organizational performance and patient experience.

PRIMARY RESPONSIBILITIES AND DUTIES

Credentialing

• Conduct primary source verification of provider and clinical staff credentials, including education, licensure, and work history.
• Prepare and maintain comprehensive credentialing files in compliance with state and federal regulations.
• Facilitate credentialing for new hires and recredentialing for existing provider and clinical staff, ensuring timely submission to committees.
• Monitor licensure expiration dates and continuing education requirements to maintain compliance.
• Manage and update credentialing software, ensuring data accuracy, system optimization, and user access to support efficient credentialing workflows.

Enrollment

• Manage the enrollment process for clinic locations and healthcare provider with Medicare, Medicaid, and private insurers.
• Prepare, submit, and track enrollment applications to ensure timely approval.
• Maintain accurate and up-to-date records of enrollment activities and provider participation status.

Collaboration

• Work closely with HR and provider management teams to support recruitment, onboarding, and eligibility processes.
• Maintain effective communication with internal and external stakeholders regarding eligibility workflows and outcomes.
• Serve as a resource on eligibility and enrollment inquiries for staff, providers, and patients.

Eligibility Development and Oversight

• Coordinate and oversee scheduling and staffing for benefit eligibility/enrollment activities aligned with HealthPoint’s initiatives.
• Serve as the subject matter expert (SME) on benefit programs to support patient access to social and insurance benefits.
• Supervise program staff, managing daily operations, evaluating clinic workflows, and ensuring adherence to agency policies and grant standards.
• Prepare and present eligibility metrics and trends to senior management.
• Foster relationships with external partners to streamline processes and maximize patient coverage options.

Performance Improvement Oversight

• Analyze eligibility workflows and metrics to identify and implement process improvement opportunities.
• Manage routine chart audits to assess performance and ensure compliance with organizational standards.
• Foster a culture of continuous improvement through data-driven methodologies.

Compliance

• Stay informed on changes in regulations affecting eligibility, credentialing, and enrollment processes.
• Assist in audits by providing required documentation and ensuring compliance with FQHC and organizational standards.
• Collaborate with compliance teams to address policy adherence.

Assisting Senior Leadership

• Promote a culture of excellence, prioritizing superior patient and employee experiences.
• Provide assessments and recommendations for program expansion and modifications.
• Maintain effective communication channels with internal stakeholders to ensure smooth operations.

Leadership Responsibilities

• Provide management, direction, and training for departmental staff.
• Develop and monitor departmental budgets.
• Maintain and update job descriptions, procedures, and employee documentation.
• Conduct hiring, performance evaluations, and disciplinary actions as needed.
• Ensure alignment of department initiatives with organizational priorities and objectives.

Additional Responsibilities

• Perform other duties as assigned, supporting organizational needs, including floating between departments and assisting stakeholders.

QUALIFICATIONS:

PROFESSIONAL/TECHNICAL KNOWLEDGE, SKILLS & ABILITIES

1) Possesses advanced general skills, including written and verbal communications skills, computational and computer skills, and mathematical knowledge frequently acquired through completion of a general Bachelor’s Degree program or Associate’s degree program OR equivalent experience in healthcare credentialing (FQHC preferred). At least two (2) years of experience in credentialing processes, regulatory compliance, and leadership may be considered in lieu of formal education.

2) Must know all aspects of credentialing/privileging/enrollment as it is performed in the organization, sufficient to effectively train or instruct others, and to serve as a resource to employees.

LICENSES & CERTIFICATION

• Texas Driver’s License – May periodically travels to clinic sites.

TECHNICAL SKILLS

1) Word Processing Skills - Prepares more complex documents in Microsoft Word, including creating tables, charts, graphs, and other elements.

2) Spreadsheet Skills - Uses Microsoft Excel to analyze data, including the use of formulas, functions, lookup tables and other standard spreadsheet elements.

3) Other Software Skills – Use of CredentialStream software preferred.

GENERAL DEVELOPMENT

1) Organizational Skills – Displays more advanced organizational skills, in order to organize projects or the work of others.

2) Problem Solving Skills – Devises effective solutions to situations encountered which include not just the specific issues related to the function, but the general concerns of the organization.

3) Communication Skills – Able to effectively communicate opinions drawn from conclusions using inference and logic.

4) Critical Thinking Skills – Uses logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.

5) Problem Resolution – Resolves conflicts that may arise because of disagreements between employees, between employees and customers/clients, or with the public, other legal entities or governmental authorities.