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Credentialing Lead
Santa Ana, CA
Position Summary
- The Credentialing Lead is a senior healthcare operations leader responsible for provider credentialing, recredentialing, and payer enrollment across a growing medical organization. This role owns the end-to-end credentialing lifecycle for physicians and advanced practice providers (APPs) and ensures compliance with NCQA, CMS, state licensing boards, and payer requirements.
- This position focuses on process improvement, compliance, audit readiness, and scalability, ensuring credentialing and enrollment operations support organizational growth without delays or regulatory risk.
- This role is eligible for a performance-based bonus incentive.
Key Responsibilities
Provider Credentialing & Enrollment
- Own the full provider credentialing and recredentialing process for physicians, APPs, and clinical staff
- Manage payer enrollment with commercial, Medicare, and Medicaid plans
- Serve as the credentialing subject-matter expert for regulatory and accreditation requirements
- Maintain credentialing policies, procedures, and documentation standards
Credentialing Operations & Process Improvement
- Evaluate and improve credentialing workflows, cycle times, and handoffs
- Standardize credentialing and enrollment processes to support multi-state growth
- Develop SLAs, checklists, escalation paths, and quality controls
- Partner with HR, Medical Operations, Revenue Cycle, Compliance, Legal, and Contracting
Compliance, Risk Management & Audits
- Ensure compliance with NCQA, CMS, state medical boards, and payer credentialing requirements
- Maintain audit-ready credentialing files and lead internal and external audits
- Identify credentialing and enrollment risks and implement mitigation plans
- Oversee clinician supervisory roster management
Team Leadership & Credentialing Management
- Lead, train, and develop credentialing and enrollment staff
- Establish performance metrics and accountability
- Create documentation and training to reduce operational risk
- Scale credentialing team structure and workflows (Director level)
Reporting & Stakeholder Communication
- Track and report on credentialing KPIs (time to credential, time to enroll, backlog, expirables)
- Provide clear status updates to executive and clinical leadership
- Set realistic credentialing and enrollment timelines with stakeholders
Minimum Qualifications
- 5+ years of experience in provider credentialing and payer enrollment
- Associate’s degree required; Bachelor’s degree in Healthcare Administration, Business, or related field preferred
- Proven experience managing provider credentialing operations in a healthcare or medical group setting
- Strong knowledge of NCQA, CMS, payer enrollment, and state licensing requirements
- Experience leading credentialing teams and improving operational performance
- Strong skills in process design, workflow optimization, and compliance management
Preferred Qualifications
- CPCS, CPMSM, or equivalent credentialing certification
- Experience in healthcare services, medical groups, MSOs, or value-based care organizations
- Experience supporting multi-state provider operations
- Experience implementing or optimizing credentialing software or enrollment platforms
Pay Range for Posted Region
$105,000 - $140,000 USD
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