Director - Credentialing

Reporting to the Sr. Director, Network Growth Operations, and partnering with Onboarding, Recruiting, Compliance, Legal, Health Plan Operations and Medical Affairs, the Director of Credentialing and Compliance will own the credentialing function. This includes managing the credentialing team, implementing new credentialing tools, and leading accreditation compliance. The ideal candidate will have a strong background in healthcare credentialing, compliance, and team leadership.

What you’ll be doing:

• Oversee all aspects of the credentialing/recredentialing of practitioners in alignment with State, Federal, and NCQA standards, as well as contracted health plan directives, including pre-delegation and annual audits of all credentialing delegated entities.
• Build and oversee Payer enrollment processes, including the submission, tracking, and follow-up of applications, to ensure timely and accurate enrollment of providers with Medicare, Medicaid, and managed care programs. This will require developing efficient, scalable workflows from the ground up.
• Manage and ensure quality related to credentialing operations, providing oversight to support the continued growth and development of the organization.
• Work cross-functionally with Product, Health Plan Operations, Medical Affairs, and Compliance teams to pull and analyze reports, ensuring that credentialing data aligns with organizational goals and regulatory standards.
• Act as the Subject Matter Expert (SME) for credentialing processes and systems, providing guidance and support to internal stakeholders to ensure compliance and efficiency.
• Establish, implement, and monitor performance goals, metrics, and processes for the Credentialing department. Prepare and maintain various reports, data, and summaries of credentialing activities.
• Lead the implementation of new credentialing tools and systems to enhance operational efficiency and compliance.
• Maintain familiarity with network adequacy and provider network standards to ensure compliance with regulatory and contractual requirements.
• Manage provider data by conducting regular audits to ensure the accuracy and integrity of provider information in credentialing databases and systems, collaborating with data management teams to develop and implement data quality initiatives, automate data entry processes, and resolve discrepancies efficiently.
• Collaborate closely with the Revenue Cycle Management (RCM) team to ensure that provider credentialing and enrollment statuses are up-to-date, facilitating successful claims processing and reimbursement.
• Provide strong leadership and development opportunities to the credentialing team, fostering a collaborative and high-performance culture.

What success looks like in this role: 

• Reduction in time to credential new providers.
• High compliance rates with NCQA and other regulatory standards.
• Successful implementation and adoption of new credentialing tools and systems.
• Positive feedback from internal and external stakeholders regarding credentialing processes.
• Effective and timely completion of all credentialing-related audits and reviews.
• Strong team performance and development, with measurable improvements in team engagement and effectiveness.

What we expect from you: 

• 10+ years of experience in healthcare credentialing, compliance, and provider network management, preferably within a health plan or managed care setting.
• Proven leadership experience managing credentialing teams of 10+ individuals and scaling operations to support business growth.
• Deep knowledge of NCQA accreditation standards and experience preparing for and leading regulatory site surveys (NCQA, TJC, CMS, etc.).
• Ability to define and drive execution at scale—you understand what right looks like and can build a clear, actionable roadmap to achieve credentialing and compliance goals.
• Strong process improvement skills, with experience implementing credentialing technology and workflow automation.
• Experience in payer relations and delegated credentialing, with a track record of navigating audits and compliance requirements.
• Exceptional analytical and problem-solving skills, with the ability to leverage data to drive operational decisions.
• Strong collaboration and stakeholder management skills, working cross-functionally with internal teams and external payers.
• Excellent communication skills, with the ability to articulate complex compliance and credentialing concepts clearly.
• Commitment to fostering a high-performance culture, with an emphasis on continuous learning and operational excellence.

Preferred Qualifications:

• NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS).
• CPHQ, CPPS, CPHRM, or similar certification.
• Experience leading contractual, regulatory and accreditation survey preparation (TJC, NCQA, Payers, etc.) and net new quality accreditation efforts.
• Experience selecting, implementing, and managing new software systems.

The target base salary range for this position is $164,900 - $214,450, and is part of a competitive total rewards package including stock options and benefits. Individual pay may vary from the target range and is determined by a number of factors including experience, location, internal pay equity, and other relevant business considerations. We review all employee pay and compensation programs annually using Radford Global Compensation Database at minimum to ensure competitive and fair pay. 

Benefits provided by Spring Health:

Note: We have even more benefits than listed here and below, your recruiter will provide more in-depth information as you continue in the interview process. Benefits are subject to individual plan requirements and eligibility criteria.

• Health, Dental, Vision benefits start on your first day at Spring. You and your dependents also receive access to One Medical accounts HSA and FSA plans are also available, with Spring contributing up to $1K for HSAs, depending on your plan type.
• Employer sponsored 401(k) match of up to 2% for retirement planning
• A yearly allotment of no cost visits to the Spring Health network of therapists, coaches, and medication management providers for you and your dependents.
• We offer competitive paid time off policies including vacation, sick leave and company holidays.
• At 6 months tenure with Spring, we offer parental leave of 18 weeks for birthing parents and 16 weeks for non-birthing parents.
• Access to Noom, a weight management program—based in psychology, that’s tailored to your unique needs and goals. 
• Access to fertility care support through Carrot, in addition to $4,000 reimbursement for related fertility expenses.
• Access to Wellhub,  which connects employees to the best options for fitness, mindfulness, nutrition, and sleep in one subscription
• Access to BrightHorizons, which provides sponsored child care, back-up care, and elder care
• Up to $1,000 Professional Development Reimbursement a year.
• $200 per year donation matching to support your favorite causes.