Director, Credentialing & Enrollment in Plantation, Florida at Pediatric Associates

PRIMARY FUNCTION

The Director of Credentialing and Enrollment leads the practice's provider credentialing, privileging, and payer enrollment functions across all locations and service lines. This role ensures every physician, nurse practitioner, physician assistant, and allied health provider is properly credentialed, privileged, and enrolled with payers in a timely, compliant, and audit-ready manner — protecting the organization's ability to bill and collect for services rendered without delay or disruption. The Director builds and manages a high-performing team, establishes scalable processes, and partners closely with Revenue Cycle, Human Resources, Legal/Compliance, and Medical Staff leadership to support the practice's continued growth. This role provides strategic and operational leadership for all provider credentialing, recredentialing, privileging support, payer enrollment, provider data integrity, and governance across the enterprise. This position ensures providers are credentialed, enrolled, and billable in a timely manner while maintaining compliance with federal, state, payer, and organizational requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This list may not include all of the duties that may be assigned.

Credentialing & Privileging Oversight

• Direct the end-to-end initial and re-credentialing process for all physicians and advanced practice providers, ensuring compliance with NCQA, CMS, state, and payer-specific standards.
• Oversee primary source verification of licensure (when applicable), education, training, board certification, DEA/CDS registrations, malpractice history, and work history for all providers.
• Maintain oversight of hospital and facility privileges where applicable, coordinating with affiliated hospital medical staff offices.
• Ensure credentialing files are complete, accurate, and audit-ready at all times; serve as the primary point of contact during payer, regulatory, or accreditation audits.
• Establish and monitor expiration tracking systems for licenses, certifications, and insurance to prevent lapses that could interrupt a provider's ability to practice or bill.

Payer Enrollment Management

• Direct the enrollment and re-enrollment of all providers with Medicaid, Medicare, and commercial payers, including pediatric-specific and managed care plans.

• Oversee group and individual provider enrollment, National Provider Identifier (NPI) management, and CAQH profile maintenance.
• Minimize enrollment-related billing delays by proactively managing timelines for new provider onboarding, locum coverage, and provider terminations or transfers.
• Partner with Revenue Cycle leadership to resolve enrollment-related claim denials, effective date discrepancies, and payer rejections.
• Monitor payer enrollment turnaround times and escalate systemic delays through payer relations channels.

Team Leadership & Operations

• Recruit, train, mentor, and manage a team of credentialing specialists and enrollment coordinators; set clear performance expectations and provide regular coaching.
• Design and continuously improve credentialing and enrollment workflows to increase efficiency, reduce provider onboarding time, and eliminate manual bottlenecks.
• Develop standard operating procedures, training materials, and quality-control checkpoints for all credentialing and enrollment functions.

Compliance & Risk Management

• Ensure the credentialing and enrollment programs comply with all applicable federal, state, and payer regulations, as well as accreditation body standards (e.g., NCQA etc as applicable).
• Maintain current knowledge of pediatric-specific payer and regulatory requirements, including Medicaid managed care and CHIP program nuances.
• Partner with Compliance and Legal on sanction screening (OIG, SAM, state exclusion lists), adverse action reporting, and delegated credentialing agreements.
• Prepare and present credentialing and enrollment compliance reports to executive leadership and, as needed.

Reporting, Analytics & Continuous Improvement

• Work with data team on developing and maintaining dashboards and scorecards tracking key metrics: average enrollment turnaround time, credentialing cycle time, expirable compliance rate, and pending application aging.
• Analyze trends to identify root causes of delays and recommend process, staffing, or technology improvements.
• Provide regular status updates to executive leadership on new provider onboarding timelines, particularly as they relate to revenue impact.

Cross-Functional Collaboration

• Serve as the primary liaison between credentialing/enrollment and Human Resources, Provider Recruitment, Revenue Cycle, IT, and Practice Operations to ensure new provider start dates align with completed credentialing and enrollment.
• Collaborate with practice leadership on the credentialing implications of new site openings, service line expansions, and payer contract changes.
• Represent the credentialing and enrollment function in payer contracting discussions and organizational strategic planning as needed.

QUALIFICATIONS

• Minimum of 7–10 years of progressive experience in provider credentialing and payer enrollment, including experience with pediatric, primary care, or multi-specialty group practices.

• Minimum of 3–5 years in a supervisory or management role leading a credentialing/enrollment team.
• Experience with large, multi-site practices or health systems strongly preferred.
• Demonstrated experience managing NCQA-compliant credentialing programs and delegated credentialing agreements preferred.
• Experience with Medicaid managed care and CHIP enrollment processes strongly preferred given the pediatric patient population.

Certifications (Preferred, Not Required)

• Certified Provider Credentialing Specialist (CPCS)
• Certified Professional Medical Services Management (CPMSM)
• Certified Provider Enrollment Specialist certification or equivalent

KNOWLEDGE, SKILLS, AND ABILITIES

Technical & Regulatory Knowledge

• In-depth knowledge of credentialing and privileging standards, including NCQA, CMS Conditions of Participation, and applicable state licensing board requirements.
• Working knowledge of payer enrollment processes across Medicare, Medicaid, and commercial/managed care plans.
• Familiarity with pediatric-specific regulatory and payer landscape, including CHIP and state Medicaid managed care nuances.
• Proficiency with credentialing and enrollment software platforms (e.g., CAQH, PECOS, Credential Stream, MD-Staff, or similar) and provider data management systems.

Leadership & Management Skills

• Proven ability to build, lead, and develop a high-performing team in a fast-paced, deadline-driven environment.
• Strong project management skills with the ability to manage multiple concurrent onboarding timelines across departments and locations.
• Sound judgment in handling confidential and sensitive provider information.

Communication & Interpersonal Skills

• Excellent verbal and written communication skills, with the ability to translate complex regulatory requirements into clear guidance for non-specialist stakeholders.
• Strong relationship-management skills for interfacing with payers, medical staff offices, and internal executive leadership.
• Ability to communicate effectively with physicians and advanced practice providers regarding documentation requirements and deadlines.

Analytical & Problem-Solving Skills

• Strong analytical skills with the ability to interpret credentialing and enrollment metrics, identify trends, and drive process improvement.
• Detail-oriented with a high degree of accuracy in reviewing and verifying provider documentation.
• Ability to proactively identify risk (e.g., expiring licenses, enrollment gaps) and implement preventive solutions before they impact operations or revenue.

Other Attributes

• High level of integrity and discretion when handling sensitive provider and organizational information.
• Adaptability to a growing, evolving organization with changing regulatory and payer requirements.
• Commitment to the mission and population served by a pediatric practice.