Job Description
Position Summary
The Director of Credentialing serves as the primary liaison between the organization and its third-party credentialing vendor, ensuring the end-to-end credentialing and recredentialing processes for all dental providers are executed accurately and on schedule. This role is responsible for overseeing vendor performance, ensuring that all practitioners maintain current, valid credentials, and verifying compliance with applicable federal, state, and insurance payer requirements. The Credentialing Director develops internal policies and procedures, manages the flow of information between the organization and the credentialing vendor, and coordinates with insurance carriers and regulatory bodies as needed.
Essential Duties and Responsibilities
• Oversee the third-party credentialing vendor’s management of the full lifecycle of provider credentialing and recredentialing, including initial applications, renewals, and payer enrollment for all dental providers (dentists and specialists).
• Serve as the day-to-day point of contact for the third-party credentialing vendor, monitoring performance against service-level agreements, ensuring accuracy and accountability, and escalating issues as needed.
• Develop, implement, and maintain credentialing policies, procedures, and workflows in compliance with NCQA, CMS, state dental boards, and payer-specific requirements.
• Maintain and manage the credentialing database (CAQH, provider enrollment portals, internal tracking systems), ensuring all provider records are accurate and up to date.
• Coordinate between the third-party credentialing vendor, insurance companies, managed care organizations, and government programs to facilitate timely provider enrollment, network participation, and contract setup.
• Monitor and track expiring licenses, DEA certificates, malpractice insurance, NPI numbers, and other required documentation, initiating renewals proactively.
• Prepare and present credentialing status reports, compliance metrics, and audit findings to senior leadership.
• Serve as the subject matter expert on credentialing regulations, industry changes, and best practices, keeping the organization informed of updates that may impact operations.
• Investigate and resolve credentialing discrepancies, denials, and compliance issues in a timely manner.
• Collaborate with human resources, billing, and clinical operations teams to ensure seamless provider onboarding and network integration.
• Lead internal and external credentialing audits and implement corrective action plans as needed.
Qualifications
Education
• Bachelor’s degree in healthcare administration, business administration, or a related field required.
Experience
• Minimum of 8 years of experience in healthcare credentialing, with at least 3 years in a supervisory or management role.
• Direct experience with dental provider credentialing and payer enrollment required.
• Demonstrated experience working with CAQH, NPPES, PECOS, and major dental insurance carriers (Delta Dental, Cigna, MetLife, Aetna, etc.).
Skills and Competencies
• In-depth knowledge of credentialing standards, NCQA accreditation requirements, and healthcare compliance regulations.
• Strong understanding of dental insurance networks, managed care contracting, and provider enrollment processes.
• Excellent organizational and project management skills with the ability to manage multiple priorities and deadlines simultaneously.
• Proficiency with credentialing software, provider databases, and Microsoft Office Suite.
• Exceptional attention to detail and commitment to data accuracy and integrity.
• Strong vendor management abilities with experience holding third-party partners accountable to performance standards and deadlines.
• Excellent verbal and written communication skills for engaging with providers, payers, and internal stakeholders.
• Analytical and problem-solving mindset with the ability to identify process improvements and implement solutions.
Working Conditions
• Primarily office-based; remote or hybrid arrangements may be available depending on organizational policy. Remote eligible within markets of operation - Texas, Florida, North Carolina, South Carolina, Georgia, and Tennessee.
• Standard business hours with occasional extended hours during audit periods or enrollment deadlines.
• Minimal travel may be required for conferences, payer meetings, or multi-site coordination.
Compensation
Compensation is commensurate with experience and qualifications. A competitive benefits package is offered, including health, dental, and vision insurance; paid time off; retirement plan; and professional development support.
This organization is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.