Senior Credentialing & Provider Enrollment Lead

POSITION SUMMARY:

The Senior Credentialing & Provider Enrollment Lead is the agency’s hands-on authority for provider credentialing and enrollment across California County Medi-Cal, Commercial Insurance, and Managed Care Organization (MCO) systems.

This role directly performs credentialing and enrollment activities while ensuring enterprise-wide consistency, regulatory compliance, audit readiness, and scalability across County, DHCS, PAVE, Commercial, and MCO payer environments. The role does not negotiate or execute contracts but requires deep fluency in how County Medi-Cal contracts, Commercial payer agreements, and MCO participation requirements drive credentialing accuracy, compliance, and reimbursement eligibility.

The role has responsibility for preparing executive-level compliance and credentialing reports and maintaining continuous readiness for County, DHCS, Commercial, and MCO audits.

GENERAL REQUIREMENTS:

Education/Experience

• Minimum of 5–7 years of combined California County Medi-Cal and Commercial Insurance / Managed Care Organization (MCO) credentialing and provider enrollment experience
• Demonstrated hands-on experience with DHCS, County MHP/DMC-ODS systems, and PAVE enrollment for California nonprofits
• Demonstrated hands-on experience with commercial and MCO credentialing platforms, including CAQH ProView and Availity
• Strong understanding of NCQA standards and delegated credentialing requirements
• Proven ability to operate hands-on while also supporting enterprise-level oversight and executive reporting

Licensure, Registration, Certification

1. Valid CA driver’s license and proof of automobile insurance.

JOB DUTIES & RESPONSIBILITIES:

Direct Credentialing & Provider Enrollment (Hands-On)

• Perform and manage credentialing and provider enrollment activities across County Medi-Cal (MHP, DMC-ODS, DHCS, PAVE) and Commercial Insurance and Managed Care Organization (MCO) payer systems.
• Perform end-to-end credentialing, re-credentialing, and enrollment activities for individual providers and applicable organizational records.
• Prepare, submit, track, and maintain credentialing and enrollment applications, supporting documentation, attestations, and renewals.
• Actively manage CAQH ProView, Availity, commercial payer portals, and County/DHCS systems to ensure data accuracy and alignment across platforms.

Enterprise Credentialing & Enrollment Oversight

• Ensure consistency, accuracy, and compliance across all credentialing and enrollment activities.
• Establish standards, controls, and tracking mechanisms to prevent gaps that could impact compliance, service delivery, or reimbursement.

Regulatory & Contract Literacy (Non-Contracting)

• Serve as the agency’s internal subject-matter expert on credentialing implications of County Medi-Cal, Commercial, and MCO payer requirements.
• Interpret regulatory and payer participation requirements to ensure credentialing aligns with scopes of service and eligibility rules.

Audit Readiness & Risk Management

• Maintain continuous readiness for County, DHCS, Commercial, and MCO audits by ensuring credentialing files and documentation are current, accurate, and audit-defensible.
• Identify systemic risks, credentialing gaps, or process weaknesses and support corrective action planning.

Reporting & Executive Communication

• Prepare clear, accurate, and timely executive-level compliance and credentialing reports, including enterprise-wide status, risks, trends, upcoming deadlines, and audit readiness indicators.

Systems Audit & SOP Development

• Conduct audits of existing credentialing and provider enrollment systems, workflows, and documentation.
• Partner with the CMDO to co-develop, document, and implement standard operating procedures (SOPs) that support compliance, consistency, and scalability.

PHYSICAL REQUIREMENTS:

• Ability to drive a motor vehicle without restrictions, often in heavy traffic and frequently long distances.
• Senses of vision, hearing and smell sufficient to regularly operate a motor vehicle, to visualize threats in the environment or risks to clients, and to operate safely in the field.
• Required to occasionally lift and carry 10-20 pounds.
• Regularly required to sit, stand, climb stairs (1 or more flights) and walk while in route to and during family visits.
• Regularly required to sit and use computer in office settings.

EOE, INCLUDING DISABILITY/VETS

We are an equal opportunity employer and consider all qualified applicants for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, ancestry, age, disability, medical condition, genetic information, marital status, veteran status, or any other protected characteristic under California law.