Reports to – Director of Medical Staff Services

Summary/Objective

The Credentialing and Enrollment Manager is responsible for overseeing the daily operations of the Credentialing & Enrollment Department under the general supervision of the Director.

This role ensures compliance with regulatory standards (NCQA, AAAHC, TJC), and payer standards.

The Manager provides leadership, training, and quality oversight to staff, while collaborating with various departments to enhance provider onboarding and management. The position plays a critical role in maintaining accurate documentation, facilitating privileging & committee processes, and supporting the strategic goals of the department and organization.

Essential Functions

Credentialing & Re-credentialing

Primary liaison for credentialing and recredentialing processes for the OHWC Lakeland Highlands Hospital. Securing start dates and coordinating any necessary or requested onboarding tasks, and expense tracking

Manage the end-to-end credentialing and re-credentialing process for physicians, nurse practitioners, physician assistants, allied practice professionals, and extenders

Verify primary source credentials, including licenses, DEA certificates, education, board certification, work history, and malpractice history; Identify red flags or discrepancies in applications and escalate them to leadership. Including monitoring, tracking, and reporting.

Oversee the workflow and productivity of the Credentialing & Enrollment Department, ensuring alignment with organizational goals and policies and procedures. 

Monitor and maintain compliance with internal standards and external regulatory/accreditation requirements. 

Privileging

Create, draft, and implement comprehensive clinical privileges forms, criteria, and dockets tailored specifically to the clinic (outpatient) and Ambulatory Surgery Center (ASC) environments.

Research, define, and establish competency metrics for core and specialized procedures 

Collaborate with Director, Department Chairs, Medical Directors, and the Credentialing Committee to regularly update and refine the delineation of privileges.

Develop specialized criteria and clinical checklists to assess and verify ongoing provider competency during re-privileging cycles.

Ensure all clinical privileges align with state licensing boards, scope of practice guidelines, and policies

Coordinate peer references, competency assessments, and delineation of privileges requests for review by department chairs and the Credentialing Committee.

Payer Enrollment (Payer Credentialing)

Manage provider enrollment with commercial insurance plans, Medicare, Medicaid, and managed care organizations.

Ensure timely submission of CAQH profiles, NPPES updates, and payer-specific applications to prevent billing delays and revenue disruption.

Maintain an accurate database of provider numbers, effective dates, and contract statuses.

Oversee day-to-day network provider enrollment across group and individual submissions, ensuring timely, accurate, and compliant applications tracked in the department’s contracted, web-based, electronic solution

Compliance & Quality Control

Maintain compliance with regulatory bodies such as The Joint Commission, NCQA, CMS, and state-specific healthcare regulations.

Conduct regular internal audits of credentialing files and privileging lists.

Oversee the maintenance of the credentialing software database and ensure secure document storage.

Ensure accuracy and quality of data within the credentialing system.

Collect and prepare documentation for regulatory audits and actively participate in audit processes. 

Supervisory Responsibility

• Interview, hire, assign work, and evaluate performance of credentialing and support personnel. 
• Provide guidance and documentation support for medical staff committees, including standing, ad hoc, and special meetings. 
• Assist in coordinating hearings and appeals, interacting with legal counsel and medical staff representatives. 
• Serve as a consultative resource to internal team and medical staff leaders, supporting strategic and operational initiatives. 
• Supports the internal credentialing committee — presenting cases, maintaining meeting minutes, and managing approvals and denials
• Represent the department in meetings and contribute to organizational planning. 
• Take ownership of assigned business operations initiatives and departmental improvement efforts. 

Required Education and Experience

Education: Bachelor’s degree in Healthcare Administration, Business, or a related field (or equivalent professional experience).

Experience: Minimum of 5 years of healthcare credentialing within large health systems/CVOs , provider enrollment, and privileging experience, with at least 2 years in a supervisory or management role.

Certifications: Current Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) through NAMSS is strongly preferred.

Skills:

Strong expertise and knowledge of NCQA, AAAHC, The Joint Commission, and CMS standards.

Strong understanding of medical staff bylaws and clinical privileging workflows.

Advanced proficiency with MD-Staff credentialing software and CAQH ProView. (Super Users and professionals with software certifications are especially valuable)

Excellent organizational, communication, and leadership skills

Ability to work with different personalities and to maintain emotional stability and calm disposition with the ability to relate positively to all levels of professionals.