Credentialing - HOD

Prime Health Services is seeking a highly skilled and results-oriented Head of Credentialing (HOD) to lead and manage the credentialing and provider enrollment department. The ideal candidate will possess deep expertise in U.S. healthcare credentialing processes, insurance payer enrollment, provider data management, and regulatory compliance. This role involves overseeing the entire credentialing lifecycle, including initial credentialing, re-credentialing, provider enrollment, demographic updates, revalidations, and contract coordination. Strong leadership skills, hands-on experience with U.S. healthcare payer systems, and the ability to streamline processes while maintaining accuracy and compliance are essential.

Key Responsibilities

Departmental Leadership & Management
- Lead and supervise the Credentialing and Provider Enrollment team.
- Set departmental goals, operational strategies, and performance benchmarks.
- Develop and enforce policies, procedures, workflows, and standard operating procedures (SOPs).
- Assign responsibilities and manage workloads based on priorities.
- Conduct regular meetings to review progress, address challenges, and communicate updates.
- Monitor employee productivity, attendance, and overall department efficiency.
- Identify operational gaps and implement improvements.
- Mentor and train team members to enhance their technical and professional skills.
- Collaborate with senior management on departmental needs and progress.

End-to-End Provider Credentialing
- Oversee credentialing processes for physicians and healthcare providers, including initial credentialing, re-credentialing, and reappointments.
- Ensure timely collection, verification, and validation of credentials and supporting documents.
- Review medical licenses, DEA certificates, board certifications, education, residency, work history, and malpractice insurance.
- Maintain complete and accurate credentialing files and ensure timely renewals.
- Conduct primary source verification (PSV) and manage background checks, exclusion screenings, and sanction monitoring.

Insurance Payer Enrollment & Management
- Manage provider enrollment with Medicare, Medicaid, and commercial payers.
- Oversee applications through payer portals, including CMS-855 and Medicare enrollment via PECOS.
- Supervise Medicaid enrollment and revalidation through state portals.
- Handle provider demographic updates, reassignment of benefits, group affiliations, and practice location additions.
- Coordinate with insurance companies on application status, approvals, and denials.
- Resolve enrollment issues and maintain accurate records of payer participation and enrollment status.
- Work closely with contracting teams on provider participation agreements and network status.

Compliance, Regulatory & Quality Assurance
- Ensure compliance with U.S. healthcare regulations, payer guidelines, and credentialing standards.
- Stay updated on CMS requirements, NCQA standards, and other regulatory guidelines.
- Verify OIG exclusions, SAM exclusions, state licenses, and sanctions.
- Implement quality control procedures and conduct internal audits to identify errors and compliance gaps.
- Maintain confidentiality and secure handling of sensitive provider information.
- Develop corrective and preventive action plans to reduce recurring errors.
- Ensure adherence to HIPAA and company data protection policies.

Required Qualifications
- Bachelor’s degree in Healthcare Administration, Business Administration, or related field.
- 4–8 years of experience in U.S. healthcare credentialing and provider enrollment.
- At least 2–3 years in a managerial or leadership role within credentialing.
- Proven ability to manage a credentialing department or large team.
- Strong knowledge of U.S. healthcare payer enrollment procedures.
- Experience with Medicare, Medicaid, and commercial insurance payers.
- Practical experience using CAQH, PECOS, NPPES, and payer enrollment portals.
- Expertise in credentialing, re-credentialing, revalidation, and primary source verification.
- Skilled in handling complex credentialing cases, application rejections, and enrollment discrepancies.
- Solid understanding of healthcare compliance, documentation, and quality assurance.

Work Location: This is an in-person position.

This role offers an excellent opportunity for a credentialing professional to lead a critical department within the healthcare revenue cycle management sector, driving operational excellence and compliance in a dynamic environment.