The Director of Provider Enrollment is responsible for leading provider enrollment operations across the health plan, ensuring accurate and timely provider onboarding, contract implementation, delegated credentialing roster management, and non-participating provider administration. This role provides strategic and operational leadership for all provider enrollment activities, driving regulatory compliance, provider data accuracy, network readiness, and operational efficiency.
The Director serves as the primary business owner for end-to-end provider enrollment processes, overseeing contract setup and activation, delegated credentialing file/load governance, non-par provider management, and implementation of initial provider set up across core systems. The role partners closely with Network Management, Credentialing, Provider Data Management, Claims, Compliance, Configuration, and Technology teams to ensure providers are accurately represented and operationally ready to support member access and claims adjudication.
Provider Enrollment & Contract Implementation
• Lead the end-to-end provider enrollment function from contract execution through provider activation.
• Oversee provider and entity onboarding activities, ensuring timely setup of all contracted providers, facilities, ancillary providers, IPAs, and delegated entities.
• Establish and maintain governance for contract implementation workflows, ensuring alignment between contracting, credentialing, enrollment, and provider data teams.
• Ensure provider records are accurately configured across all downstream operational systems.
• Develop standardized enrollment procedures, controls, and quality assurance processes.
Delegated Credentialing Management
• Own the end-to-end operational management of delegated credentialing roster submissions and provider loads.
• Establish delegated provider onboarding standards, submission requirements, loading protocols, and validation controls.
• Partner with Delegation Oversight teams to ensure provider roster submissions meet regulatory, contractual, and accreditation requirements.
• Monitor delegated provider load accuracy, turnaround times, and compliance with service level agreements.
• Lead remediation efforts for roster discrepancies and audit findings.
Non-Par and Out-of-Network Provider Management
• Provide strategic oversight of non-participating and non-contracted provider enrollment processes.
• Develop policies and workflows for setup, maintenance, monitoring, and reporting of non-par providers.
• Partner with Claims, Network Management, and Provider Data teams to support accurate claims of adjudication and provider identification.
• Ensure consistent application of business rules governing non-participating provider records.
• Monitor trends and operational risks related to out-of-network provider activity.
Provider Data Governance
• Establish provider enrollment data standards and quality controls.
• Lead data validation, reconciliation, and audit activities across enrollment and credentialing processes.
• Develop performance metrics and dashboards to monitor provider onboarding, delegate load performance, inventory aging, and enrollment cycle times.
• Support initiatives to improve provider directory accuracy and provider data integrity in partnership with Provider Data Management and Data Quality Management Director.
Regulatory Compliance & Audit Readiness
• Ensure provider enrollment operations comply with CMS, NCQA, State, and accreditation requirements.
• Collaborate with Compliance and Credentialing leadership to support audits, surveys, and delegated oversight reviews.
• Develop and maintain policies, procedures, and documentation supporting regulatory compliance.
• Implement controls to mitigate operational and compliance risks.
Leadership & Operational Excellence
• Lead, develop, and mentor provider enrollment managers and operational teams.
• Establish productivity, quality, and service performance standards.
• Drive process improvement initiatives that leverage automation, workflow optimization, and technology solutions.
• Partner with executive leadership to support network growth, market expansion, and strategic provider initiatives.
• Manage departmental budgets, vendor relationships, and operational performance.
Job Requirements:
EXPERIENCE
Required:
• 10+ years of healthcare operations experience within a health plan, managed care organization, provider network, or healthcare administration environment.
• 5+ years of leadership experience managing provider enrollment, credentialing, provider data management, network operations, or related functions.
• Demonstrated experience managing delegated credentialing programs and provider roster governance.
• Experience overseeing provider contract implementation and onboarding operations.
• Strong knowledge of provider data, credentialing, enrollment, and network management processes.
Preferred:
• Experience leading large-scale operational transformation initiatives.
EDUCATION
Required:
• Bachelor's degree in healthcare administration, Business Administration, Public Health, or related field.
Preferred
• Master's degree a plus.
SPECIALIZED SKILLS
• Deep understanding of provider enrollment operations, delegated credentialing, delegation oversight, provider data management, network administration, non-par and out-of-network provider processing, CMS and NCQA requirements, provider directory accuracy standards, and claims and downstream operational impacts.
• Strong analytical and operational leadership skills.
• Excellent stakeholder management and executive communication capabilities.
Pay Range: $126,422.00 - $189,634.00
Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.
