[Remote] Director, Credentialing Operations (Health Plan Credentialing Experience)

Note: The job is a remote job and is open to candidates in USA. TriWest Healthcare Alliance is dedicated to serving America's heroes by connecting them to healthcare in the community. The Director of Credentialing Operations will lead and oversee the operational performance of provider credentialing functions, ensuring compliance, quality, and efficiency in credentialing processes.

Responsibilities

• Provides strategic leadership and operational oversight for the Provider Network Management – Credentialing Department, ensuring alignment with organizational goals, regulatory requirements, and accreditation standards. Leads, mentors, and develops staff to achieve high performance, accountability, and continuous improvement
• Directs end-to-end credentialing and re-credentialing operations, ensuring timely completion of credentialing activities in accordance with established service level agreements (SLAs), quality standards, and regulatory requirements
• Oversees departmental productivity, work production, workload distribution, and operational performance through the development and monitoring of key performance indicators (KPIs), metrics, and service delivery targets
• Ensures the quality, accuracy, and integrity of credentialing and provider data across credentialing and provider data management systems, including oversight of primary source verification, data entry, and provider record maintenance
• Establishes and maintains robust quality assurance and audit processes to ensure credentialing activities meet internal standards as well as regulatory and accreditation requirements
• Oversees end-to-end delegated credentialing program, including governance, monitoring, and auditing of network subcontractors and delegated entities to ensure compliance with contractual, regulatory, and accreditation requirements. Directs credentialing audits for network subcontractors and delegated entities, including review of audit findings, development of corrective action plans, and reporting outcomes
• Oversees the coordination and administration of Credentialing Committee activities, ensuring complete, accurate, and compliant credentialing files; development and management of meeting agendas and minutes; and strict adherence to committee governance policies, procedures, and documentation standards
• Identifies operational risks, recurring issues, and workflow inefficiencies within credentialing processes, and lead the development and implementation of process improvements and system enhancements
• Collaborates cross-functionally with Provider Services, Compliance, Legal, Medical Management, IT, and other operational areas to support enterprise initiatives and continuous improvement efforts
• Fosters strong relationships with network providers, delegated entities, and internal stakeholders to ensure timely resolution of credentialing issues and to support a positive provider experience
• Develops and delivers executive-level performance reports and dashboards that provide visibility into credentialing operations, service levels, quality outcomes, and operational trends for senior leadership and key stakeholders
• Establishes staffing strategies and allocates resources to meet operational demands and service level commitments. Recruits, trains, coaches, and develops staff to ensure operational readiness and professional growth
• Assesses and defines budgetary requirements to support departmental objectives, recommends annual funding needs with supporting business cases for system enhancements, and forecasts resource requirements in alignment with industry trends and emerging developments
• Maintains regular and reliable attendance and demonstrates leadership that reflects organizational values and commitment to service excellence

Skills

• Bachelor's degree in business administration, healthcare administration, or related field or equivalent experience
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• 5 years of experience in a managed care or payer environment
• 5+ years of progressively responsible people management experience to include managing leaders in the healthcare industry
• Minimum of 3 years of experience managing provider credentialing and data applications/systems
• Proven experience leading and managing large teams in a high-volume, production-driven environment
• Experience with URAC, NCQA, or other equivalent accreditation standards
• Experience in strategic planning, program design and management, and team leadership with a focus on leadership and staff development
• Experience in government healthcare delivery programs, such as Veterans Affairs, TRICARE, or Medicare

Benefits

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time
• Frequent pay raises
• Overtime opportunities to earn even more
• Recognition and reward programs

Company Overview