Director of Licensing & Credentialing

Position Summary

The Director, Provider Credentialing & Licensing Operations ensures every USOSM oral surgeon is properly licensed and credentialed with payers, on time and in every state where we operate. This leader works closely with our credentialing vendor partner to build new processes and workflows, defining vendor, practice leader and support center roles and responsibilities. Compliance is central to the role: this leader makes sure every surgeons licenses, permits, certifications and privileges stay current, meet each states requirements and are audit ready. This leader will partner to build USOSMs new delegated credentialing program, including policies and procedures to meet regulatory credentialing requirements including NCQA, while overseeing the traditional credentialing process that will always be part of our work.

The ideal candidate is an experienced credentialing leader who has built programs, not just run them. They set direction for the function, lead a team of four, manage vendors and tools, use data and reporting to oversee performance, hold a vendor accountable through clear KPIs and SLAs, and communicate clearly with executives, business partners, surgeons and practice leaders.

Key Responsibilities

1. Vendor partnership and process design

- Own USOSMs relationship with its credentialing vendor partners, including quarterly business reviews, contract performance and escalations to vendor leadership.

- Work with the vendor to build and refine processes, workflows and handoffs between the vendor and the in-house team.

- Set communication cadence, escalation paths and performance expectations with the vendor.

- Provide oversight to provider data, payer rosters and application status are accurate and reconciled between USOSM and the vendor.

- Establish KPIs and SLA reporting to improve credentialing TAT, ensuring surgeons are ready to treat patients.

2. Team leadership and workflows

- Build, lead and develop a team of four (three direct reports, plus a Licensing Onboarding Specialist reporting to the Supervisor, Onboarding & Transition) across licensing, credentialing oversight, compliance and reporting, including hiring, performance management and succession planning.

- Design and document new workflows for surgeon onboarding, licensing, hospital privileges, credentialing, recredentialing and payer enrollment.

- Own the departments staffing plan and budget, and scale the workflow and processes as USOSM adds practices, states and delegated payers.

- Build and deliver education and communication materials to face various audiences including executives, business partners, surgeons and clinical governance board, and practice leaders to provide education on credentialing and license operations, performance and outcomes geared towards improvement in readiness to treat.

3. Licensing and compliance

- Oversee licensing for oral surgeons, including state dental and medical licenses, board certifications, anesthesia and sedation permits, DEA and state controlled-substance registrations, hospital privileges and required exams.

- Build and maintain a state-by-state reference of licensing, permit and renewal requirements, and know where to look when rules change. Partner with compliance and legal experts to ensure state requirements and regulations are met.

- Track all expirations and renewals so no surgeon lapses.

- Keep provider files accurate and audit-ready, and escalate compliance risks.

- Partner with practice leaders onboarding so new surgeons are licensed and ready to treat.

- Build hospital privilege workflow and education materials to support practice leaders enrollment process.

4. Delegated credentialing program

- Build and lead USOSMs new delegated credentialing program with payers, including processes and workflows designed for delegation, which differ from traditional credentialing.

- Own credentialing policies and procedures, and communication with vendors credentialing committee, using file review standards that meet payer delegation requirements and NCQA standards.

- Represent USOSM in payer pre-delegation and annual delegation audits, and run regular internal audits of vendor files.

- Oversee monthly roster reconciliation and reporting with each delegated payer, including adds, terms and demographic changes.

- Provide close oversight of the vendors delegated work, so USOSM stays compliant with every payer delegation agreement.

- Grow the delegated program over time, adding payers with the Director of Payer Strategy where delegation makes sense.

5. Traditional credentialing oversight

- Oversee the vendors traditional credentialing and recredentialing with dental and medical payers that are not under delegation.

- Monitor application status, follow-up and effective dates, so surgeons can bill in network as soon as possible.

- Maintain oversight of provider data (CAQH, NPPES and payer rosters) accurate and current.

- Prioritize credentialing with payers based on network decisions from the Director of Payer Strategy.

- Stand up and manage a ticket-based service process so practice leaders can request help, and the team can track, prioritize and resolve credentialing or hospital privileges issues.

6. Hospital privileges support and oversight

- Oversee the new hospital privileges enrollment model, in which practice leaders manage hospital enrollments for their surgeons at the practice level, with this team providing support when needed.

- Build a dedicated workflow for hospital privileges, including standard steps, required documents, timelines and handoffs between practices and the central team.

- Lead the team in supporting practice leaders and resolving escalated issues with hospital medical staff offices.

- Monitor privileges status, reappointment dates and open support tickets across practices, and step in when an issue risks a lapse in privileges.

- Provide training, templates and guidance to practice leaders on the privileges process.

7. Reporting, KPIs and vendor SLAs

- Manage the vendor to the SLAs in its contract, and run regular performance reviews and business reviews.

- Track KPIs such as credentialing turnaround time, backlog, effective dates, approval rates, renewal compliance, delegation audit results, roster reconciliation accuracy, hospital privileges ticket volume and resolution time, and time-to-bill for new surgeons.

- Extract reports and service tickets from vendor portals, ticketing and credentialing systems, and build and own monthly dashboards and status reports for leadership, practices and the payer strategy team.

- Present the functions performance, risks and recommendations to executive leadership, and lead corrective action with the vendor when performance falls short.

Qualifications

Required

- Bachelors degree in healthcare administration, business or a related field.

- 8+ years of experience in provider credentialing, licensing or payer enrollment, in dental, medical or another healthcare setting.

- 5+ years managing people.

- Experience partnering with an outsourced credentialing vendor to build processes and workflows.

- Hands-on experience building or running a delegated credentialing program, including policies, credentialing committee, payer delegation audits and monthly roster reconciliation.

- Basic understanding of state licensing, permit and compliance requirements, and the ability to research them state by state.

- Proven experience managing vendors through SLAs, KPIs and scorecards, and managing a department budget.

- Experience designing and documenting workflows and defining team roles, including setting up and managing a ticket-based service process (for example, ServiceNow, Zendesk, Jira or similar).

- Strong reporting experience, including using credentialing, ticketing and vendor systems to extract reports and service tickets, and building KPI dashboards in advanced Excel (Power BI or similar a plus).

- Very strong written and verbal communication skills, including presenting to executives, and a self-starter who works well with limited direction.

Preferred

- Dental credentialing experience.

- Experience with oral and maxillofacial surgery, or specialties that credential with both dental and medical plans.

- Experience with credentialing and enrollment software (for example, CAQH and/or other tools).

- Knowledge of credentialing standards (for example NCQA), and/or credentialing certification (CPCS or CPMSM).