Director of Credentialing

ABOUT PLUTUS HEALTHPlutus Health is a Dallas-headquartered healthcare revenue cycle management company serving providers across multiple specialties. With 1,600+ employees in the United States, India, and the Philippines, we deliver end-to-end RCM services including medical billing, credentialing, payer enrollment, and contracting.POSITION OVERVIEWThe Director of Credentialing & Contracting will provide strategic and operational leadership for provider credentialing, re-credentialing, payer enrollment, and payer contract negotiation. This senior role requires deep expertise in healthcare credentialing and payer contracting, strong team leadership skills, and the ability to implement technology and automation to drive efficiency, compliance, and revenue impact across multiple clients and payer relationships.KEY RESPONSIBILITIESStrategic Leadership & OperationsDevelop and execute credentialing and contracting strategies aligned with company growth.Lead and mentor a large, offshore-heavy team of credentialing specialists and contracting analysts.Define and track KPIs, SLAs, and quality metrics; drive continuous improvement.Design scalable processes to support rapid expansion.Partner with RCM operations, sales, finance, legal/compliance, and executive leadership.Provide executive-level reporting on credentialing status, payer performance, and revenue impact.Credentialing & Provider EnrollmentOversee end-to-end credentialing for 700+ provider applications monthly across specialties.Manage initial credentialing, re-credentialing, and enrollment for Medicare, Medicaid, and commercial payers.Achieve 98%+ SLA compliance and target turnaround times (90–120 days initial; 60–90 days re-credentialing).Ensure accurate primary source verification (licenses, DEA, board certifications, education, work history).Oversee CAQH profile management and hospital privileging across multiple facilities.Maintain strong relationships with payer enrollment teams to expedite approvals.Implement credentialing technology and automation to reduce manual work.Technology, AI & AutomationLead implementation of Agentic AI, RPA, and workflow automation to reduce processing time by 20–30%.Deploy AI tools for application completion, document extraction, and data validation.Implement automated roster management, license monitoring, and re-credentialing alerts.Use contract management platforms for rate tracking, renewal alerts, and fee comparisons.Integrate credentialing systems with billing platforms to ensure clean provider data.Evaluate and implement credentialing and contract management software; build dashboards for real-time metrics.Champion digital transformation initiatives across credentialing and contracting.Payer Contracting & NegotiationsLead payer negotiations for commercial, Medicare Advantage, and Medicaid managed care plans.Analyze reimbursement rates using technology platforms; execute strategies to improve rates by 2–5%.Review and negotiate participation agreements (fee schedules, payment terms, denial/appeal processes, credentialing clauses).Manage contract renewal cycles with proactive planning and automated tracking.Maintain a centralized contract database with rate tracking and expiration alerts.Identify underperforming contracts using analytics and drive renegotiation or termination.Ensure accurate contract loading into billing systems; negotiate carve-outs for high-volume CPT codes.Regulatory Compliance & QualityEnsure compliance with NCQA, URAC, CMS, The Joint Commission, and state-specific standards.Maintain expertise in NPDB, OIG LEIE, SAM.gov, and state sanctions.Oversee credentialing committee processes and documentation.Conduct regular audits of files and contracts; implement corrective actions.Ensure HIPAA compliance and manage delegation oversight activities for IPAs and MSOs.Client & Stakeholder ManagementServe as primary escalation point for complex credentialing and contracting issues.Conduct client presentations on status, performance, and strategic recommendations.Support sales during new client implementations and RFPs.Build trusted relationships with provider leadership and practice administrators.Set and manage expectations around timelines and negotiation outcomes.Financial Analysis & Revenue OptimizationAnalyze payer mix and reimbursement to identify revenue opportunities.Perform fee schedule comparisons and build business cases for renegotiations.Track contract value realization and underpayments using analytics tools.Model financial impact of contract changes and collaborate with finance and RCM teams.REQUIRED QUALIFICATIONS12–15+ years of progressive experience in US healthcare credentialing and provider enrollment.5+ years leading teams of 50+ in credentialing and/or contracting.Proven experience managing 500+ credentialing applications monthly at scale.Deep knowledge of Medicare, Medicaid, and commercial payer requirements across multiple states.Demonstrated success negotiating payer contracts with measurable rate improvements.Hands-on experience implementing AI, RPA, or automation in credentialing or contract workflows.Expert knowledge of CAQH, PECOS, NPPES, and major payer portals (UHC, Anthem/BCBS, Cigna, Humana, Aetna).Strong understanding of fee schedules, reimbursement methodologies, and payment terms.Experience with NCQA/URAC/Joint Commission standards.Advanced Excel skills (data analysis, pivot tables, complex formulas); familiarity with BI tools preferred.Excellent client-facing communication and executive presentation skills.Bachelor’s in Healthcare Administration, Business, or related field; Master’s preferred.Ability to work US business hours (evening/night shift from India).PREFERRED QUALIFICATIONSNAMSS certification (CPCS or CPMSM).Track record leading automation projects delivering 20%+ efficiency gains.Background in healthcare RCM or medical billing.Experience managing credentialing for numerous specialties and multi-facility groups.Hands-on experience with credentialing platforms (e.g., Symplr, Cactus, CredentialStream, MD-Staff) and contract management tools.Knowledge of value-based contracts and ACO/CIN credentialing.Experience with delegation oversight for IPAs/MSOs and offshore team management.Familiarity with AI/ML in healthcare operations (document extraction, workflow automation, predictive analytics).TECHNICAL COMPETENCIESCredentialing: CAQH ProView, PECOS, NPPES, state Medicaid systems.Verification: NPDB, OIG LEIE, SAM.gov, SSA Death Master File, Medicare Opt-Out, state licensing boards.Payer Portals: Major commercial payers, Medicare, Medicaid MCOs.Automation & AI: RPA platforms, AI document extraction, workflow automation.Reporting: Advanced Excel; experience with Power BI/Tableau a plus.LEADERSHIP COMPETENCIESStrategic thinking and ability to translate business goals into execution.Strong people leadership: hiring, coaching, and performance management.Proven ability to build and scale high-performing teams.Excellent negotiation and stakeholder management skills.Data-driven decision making and strong financial acumen.Change management and technology adoption experience.Executive presence and strong communication skills.Problem-solving and innovation mindset.KEY SUCCESS METRICS98%+ SLA achievement and on-time credentialing.Target credentialing turnaround times met or improved.20–30% reduction in manual effort via automation.100% CAQH accuracy and clean audits.2–5% improvement in renegotiated payer rates.Zero critical compliance violations and minimal client escalations.High client satisfaction and strong team engagement.REPORTING STRUCTUREReports to: VP of Revenue Cycle ManagementDirect Reports: 3–5 credentialing/contracting managersTeam: 50+ credentialing specialists and contracting analystsPartners: RCM operations, finance, sales, client success, legal/compliance, IT/automationCOMPENSATION & BENEFITSCompetitive salary: ₹35–45 LPA (based on experience).Performance bonus up to 20% of base.Night shift allowance for US hours.Comprehensive health insurance for employee and dependents.NAMSS certification support and continuing education.Hybrid model (3 days office / 2 days remote) in Bangalore (or Coimbatore).Leadership development and exposure to US leadership; potential travel.WORK ENVIRONMENTLocation: Bangalore, India (alternate: Coimbatore).Fast-paced, client-focused, deadline-driven environment with high accountability and strong emphasis on innovation.HOW TO APPLY Send the following to careers@plutushealthinc.com with subject line: Director Credentialing & Contracting – [Your Name]Resume detailing credentialing volumes, payer contracts, and automation projects.Cover letter addressing: (a) largest credentialing operation managed, (b) most successful payer negotiation, (c) automation/AI projects led, (d) leadership philosophy.References from prior credentialing or healthcare leadership roles.