Associate Director, Credentialing and Network Compliance

Reporting to the Sr. Director, Network Growth Operations, and partnering with Onboarding, Recruiting, Compliance, Legal, Health Plan Operations and Medical Affairs, the Associate 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.
• 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.
• Oversee provider 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.
• 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 data management teams to develop and implement data quality initiatives, automate data entry processes, and resolve data 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: 

• Minimum of 7 years of experience in a quality-focused role in healthcare, with a strong emphasis on provider credentialing, provider data integrity, and managing provider network adequacy within a health plan setting
• Demonstrated experience in developing policy and procedure documentation.
• Knowledge of NCQA Accreditation requirements and demonstrated experience preparing for and leading accreditation and regulatory site surveys (NCQA, TJC, CMS, etc.).
• Knowledge of medical credentialing and privileging procedures and standards.
• Experience in project management and partnering with cross-functional teams.
• Data-driven and analytical by nature with demonstrated skills in gathering, analyzing, and interpreting data in Google Sheets/MS Excel.
• Excellent oral and written communication skills—ability to fluently tell a compelling clinical, compliance, or business story with data.
• A thoughtful and collaborative approach to problem-solving.
• Humility, resourcefulness, empathy, and professionalism.
• Demonstrated passion for, and understanding of, mental health and the broader U.S. healthcare system.

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 $126,740- $158,425, 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. All benefits are subject to individual plan requirements and eligibility criteria.

• Health, Dental, Vision benefits start on your first day at Spring Health. You and your dependents also receive an individual One Medical account which is valued at $199/year per user. HSA and FSA plans are also available.
• Employer sponsored 401(k) match of up to 2%
• A yearly allotment of no cost visits to the Spring Health network of therapists, coaches, and medication management providers for you and your dependents.
• Generous paid time off, 10 sick days, 12 paid holidays throughout the year, and a 1 month sabbatical leave granted at your 4 year anniversary
• We offer parental leave up to 18 weeks, depending on your eligibility including tenure and medical situation.
• Access to fertility care support through Carrot, in addition to $4,000 reimbursement for related fertility expenses.
• Access to Wellhub, an on-demand virtual benefit that provides wellbeing coaching, and budget management.
• Up to $1,000 Professional Development Reimbursement a year.
• $200 per year donation matching to support your favorite causes.