FIND_THE_RIGHTJOB.
Director of Credentialing and Delegated Operations
JOB_REQUIREMENTS
Hires in
Not specified
Employment Type
Not specified
Company Location
Not specified
Salary
Not specified
Summary:
Lead the creation and ongoing management of PSW’s Credentialing Department, ensuring compliance with NCQA, CMS, and payer requirements. Serve as the primary delegated entity for PSW customers, including health plans (payers), independent physician associations/groups (IPAs) and clinically integrated network (CINs). Oversee credentialing operations, contracting integration, and provider network alignment to support strategic growth and value-based care initiatives. In addition, this role will lead the strategic planning and implementation of PSW’s Credentials Verification Organization (CVO) to support delegated credentialing for health plans and provider networks, ensuring compliance with NCQA and other accreditation standards.
Essential Functions:
Department Establishment & Leadership:
Department Establishment & Leadership:
- Design and implement PSW’s Credentialing Department, including policies, workflows, and staffing.
- Develop and maintain the Credentialing Delegation Manual and ensure annual updates.
- Collaborates to develop communications, presentations, proposals and other work product as needed.
- Works closely with compliance to ensure credentialing requirements are met, including regular audits
- Lead organizational initiatives within areas of oversight to ensure efficiency and maintain compliance with the policies and standards, government laws and regulations.
- Ensure compliance with NCQA, CMS, and payer standards through audits and performance monitoring.
- Primary point of contact for all auditing, reporting, performance improvement and/or other follow-up concerning Credentialing System Controls, including oversight/compliance of any sub-delegations.
- Serve as primary liaison for health plans and CINs regarding credentialing delegation agreements.
- Collaborate with contracting, network management, provider engagement and operations teams to align credentialing processes with network development and payer agreements.
- Support onboarding and contracting workflows to ensure timely provider participation.
- Design and implement PSW’s CVO infrastructure, including technology, workflows, and staffing models.
- Develop policies and procedures to meet NCQA, URAC, and CMS standards for credentialing and primary source verification.
- Lead readiness activities for NCQA accreditation and maintain compliance post-certification.
- Evaluate existing, and/or select credentialing technology platforms to support CVO operations.
- Establish service-level agreements (SLAs) for delegated credentialing services provided to payers, IPAs & CINs.
- Lead Credentialing Committee meetings with the Medical Director.
- Oversee sub-delegation arrangements and ensure compliance with all regulatory requirements.
- Provides critical thinking, developing insights from data reports and assists stakeholders with the translation of information to knowledge and useful action plans.
- Plays a critical role in performance management by guiding actionable initiatives from data; measuring progress and outcomes and helping implement interventions where applicable
- Develop KPIs for credentialing operations and delegated functions.
- Drive continuous improvement initiatives using data analytics and stakeholder feedback to increase efficiency and outcomes.
- Hire, train, and manage credentialing staff.
- Develop departmental budget and monitor financial performance.
- Manages all credentialing and re-credentialing activities according to P&Ps and in compliance with NCQA.
- Leads credentialing committee meetings in conjunction with the medical director
- Oversees required monthly ongoing monitoring activities, ensuring compliance with all NCQA, CMS, and health plan requirements.
- Monitor performance, develop, and implement solutions to address process and gaps across delegated operations.
- Ensures staff compliance with PSW policies and procedures with special emphasis on HIPAA requirements
- Builds and leverages cross-functional collaborative relationships to facilitate a team-work oriented atmosphere and achieve company goals.
- Build scalable processes to expand CVO services to external clients.
- Develop pricing models and operational metrics for CVO services.
Knowledge/Skills/Abilities:
- Excellent computer proficiency (MS Office – Word, Excel, Outlook) including being able to effectively maintain written and computer records in accordance with regulatory agencies.
- Set a positive example by displaying a pleasant and approachable demeanor at all times.
- Proactive team player, strong follow-through, quick decision-making abilities and ability to problem solve.
- Interpersonal skills, with the ability to build strong relationships at all levels.
- Strong verbal and written communication skills with customers, supervisors and co-workers.
- Strong organizational, time management and prioritization skills.
- Self-starter. Ability to set priorities and keep to projected schedules.
Required Education and/or Work Experience:
- Experience in building or managing a CVO or similar credentialing entity.
- Knowledge of NCQA accreditation standards and delegated credentialing requirements.
- Proven ability to lead large-scale operational transformation projects.
Preferred Education and/or Work Experience:
- Bachelor’s degree in business, Health Administration, or related field (Master’s preferred).
- 7+ years in credentialing with health plan and provider network experience, i.e.) facility, ancillary, practitioner, including delegated credentialing.
- Proven experience in contracting integration, provider operations, and team leadership.
- Strong knowledge of NCQA standards and delegated credentialing requirements. Health plan payer knowledge and changes within the Washington State healthcare landscape
- CIN experience with a provider perspective and strong orientation to value-based care principles
Preferred but not required Certificates, Licenses and Registrations:
- CPCS or CPMSM certification.
- Experience with credentialing technology platforms (e.g., MD-Staff, MedTrainer, Symplr, Verifiable).
- Prior involvement in NCQA accreditation preparation.
PSW does not typically hire new employees near the top of the salary range.
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Flexible Spending Account (FSA)
- Health Savings Account (HSA)
- Health insurance
- Life insurance
- Paid time off
- Tuition reimbursement
- Vision insurance
Similar jobs
No similar jobs found
© 2026 Qureos. All rights reserved.