Director, Provider Credentialing

Job Summary:

The Director of Credentialing will lead and manage provider credentialing and recredentialing function at ArchWell Health. This individual will ensure compliance with NCQA, CMS, and state-specific regulatory requirements while supporting rapid provider onboarding in a value-based care environment. This role will lead a team of analysts to provide guidance and oversight of credentialing new providers and maintaining current provider files for our quickly growing medical group. This role requires a strategic and detail-oriented approach to oversee the end-to-end credentialing process, including: submitting and tracking credentialing applications to various contracted managed care plans and government payors for oncoming providers; validating the accuracy of provider data loads in payor networks; maintaining accurate and updated data for all providers within the group; tracking the expiration of certification and licenses; support the markets with timely and accurate communications related to provider credentialing and provider data loads; and will act as a liaison between market leadership, payors, external credentialing service firms, and medical staff, including physicians.

Duties/Responsibilities

• Oversee end-to-end credentialing and recredentialing for all contracted providers
• Evaluate and improve the ArchWell Health credentialing workplan and processes, including all required credentialing for providers and facilities as dictated by government payors and contracted managed care plans
• Collaborate cross-functionally with Market Operations, Human Resources, Providers, and IT to ensure providers are credentialed and onboarded in a timely manner, streamline process and support network growth
• Maintain compliance with regulatory and accreditation standards (e.g., NCQA, CMS, state DMHC/DOH).
• Lead and manage credentialing team operations, including performance management and process improvement initiatives.
• Manage credentialing software and data integrity across systems.
• Prepare for and lead credentialing audits, both internal and external.
• Serve as the subject matter expert on credentialing best practices, ensuring timely, accurate, and efficient operations.
• Oversee all necessary credentialing for providers and facilities, including conducting background checks, contacting licensing boards, reviewing license applications, obtaining education information, completing references, ensuring the facility is operating within state and federal regulations
• Regular status reporting to key stakeholders on credentialing and provider directory loads for providers
• Reconciliation and timely updates for payor provider data and provider directories to ensure that directories are accurate to support member empanelment required under risk contracts with payors.
• Own payor reporting, including data reporting and monthly exclusion checks
• Oversee ongoing renewals for all required physician licenses and credentials
• Act as a liaison between government payors and managed care plans, outsourced credentialing services, and ArchWell Health medical staff, including physicians
• Additional duties as assigned

Required Skills/Abilities:

• Strong understanding of Medicare, Medicaid, and managed care plan credentialing requirements, plus familiarity with CAQH (Council for Affordable Quality Healthcare)
• Ability to build strong cross-functional relationships within an organization to drive projects and initiatives to completion
• Ability to partner and communicate with providers in a professional manner to assist in the completion of the CAQH applications

• Demonstrated track record of successfully executing in a high growth environment with limited infrastructure
• Strong organization and written communication skills
• Ability to communicate well with all levels of staff, providers, and patient referral sources

Education and Experience:

• Bachelor's degree in healthcare administration, business, or related field required; master's degree (MPH, MHA, MBA) preferred.
• Minimum of 7 years of progressive experience in provider credentialing within a healthcare organization, with at least 3 years in a leadership or management role.
• Deep understanding of federal and state regulatory requirements including NCQA, CMS, and state-specific guidelines.
• Prior experience supporting credentialing of providers in a multi-site and multi-state healthcare delivery organization.
• Familiarity with managed care operations, value-based care models, and MSO structures.

• Proficiency in credentialing software platforms preferred
• Strong data management, documentation, and compliance tracking capabilities.
• Demonstrated success in leading high-performing teams and implementing process improvements in credentialing operations.
• Strong interpersonal and communication skills, with the ability to work collaboratively across clinical, legal, and operational teams.
• Embodies and serves as a role model of ArchWell Health's Values: Be compassionate. Strive for excellence. Earn trust. Show respect. Stay resilient. Always do the right thing

ArchWell Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to their race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected classification.