Director, Provider Enrollment

This is a fully remote position, open to applicants in United States.

📋 Description

• Oversee the entire provider enrollment process from contract signing to provider activation.

• Manage onboarding activities for contracted providers, facilities, ancillary providers, IPAs, and delegated entities.

• Create governance structures for contract implementation workflows involving contracting, credentialing, enrollment, and provider data teams.

• Ensure accurate configuration of provider records across downstream operational systems.

• Design standardized procedures for enrollment, controls, and quality assurance processes.

• Supervise delegated credentialing roster submissions, provider loads, onboarding standards, loading protocols, and validation controls.

• Collaborate with Delegation Oversight teams to ensure compliance with regulatory, contractual, and accreditation standards.

• Track the accuracy of delegated provider loads, turnaround times, and adherence to service-level agreements.

• Lead efforts to resolve discrepancies in rosters and address audit findings.

• Manage the enrollment processes, policies, workflows, monitoring, and reporting for non-participating and non-contracted providers.

• Work with Claims, Network Management, and Provider Data teams to ensure accurate claims processing and provider identification.

• Set standards for provider enrollment data and establish quality controls.

• Direct data validation, reconciliation, and audit activities.

• Create performance metrics and dashboards to monitor provider onboarding, delegate load performance, inventory aging, and enrollment cycle times.

• Contribute to initiatives aimed at maintaining provider directory accuracy and data integrity.

• Ensure compliance with CMS, NCQA, state regulations, and accreditation standards.

• Assist with audits, surveys, and delegated oversight evaluations.

• Maintain compliance policies, procedures, and necessary documentation.

• Implement controls to reduce operational and compliance risks.

• Mentor and develop provider enrollment managers and operational teams.

• Establish standards for productivity, quality, and service performance.

• Promote process enhancements through automation, workflow optimization, and technology solutions.

• Collaborate with executive leadership on network growth, market expansion, and strategic provider initiatives.

• Manage departmental budgets, vendor relationships, and operational performance.

⛳️ Requirements

• A minimum of 10 years of experience in healthcare operations within a health plan, managed care organization, provider network, or healthcare administration setting.

• At least 5 years of leadership experience in managing provider enrollment, credentialing, provider data management, network operations, or similar functions.

• Proven experience in overseeing delegated credentialing programs and managing provider roster governance.

• Experience in managing provider contract implementation and onboarding operations.

• Strong knowledge of provider data, credentialing, enrollment, and network management processes.

• Bachelor’s degree in healthcare administration, Business Administration, Public Health, or a related discipline.

• Comprehensive understanding of provider enrollment operations, delegated credentialing, delegation oversight, provider data management, network administration, non-part and out-of-network provider processing, CMS and NCQA requirements, provider directory accuracy standards, and the implications for claims and downstream operations.

• Exceptional analytical and operational leadership abilities.

• Excellent skills in stakeholder management and executive communication.

🏝️ Benefits

• Competitive salary and performance-based incentives.

• Comprehensive health, dental, and vision insurance plans.

• Generous paid time off and holiday policies.

• Retirement savings plan with company matching contributions.

• Opportunities for professional development and career advancement.