Provider Enrollment Specialist

Assistant Vice President (AVP), Provider Enrollment & Credentialing The Assistant Vice President (AVP), Provider Enrollment & Credentialing provides strategic and operational leadership for all provider credentialing, privileging, and payer enrollment functions across the health system. This role is accountable for building and sustaining a high-performing, compliant, and scalable infrastructure that ensures providers are credentialed, privileges, and enrolled with government and commercial payers accurately and efficiently to directly protect the organization's ability to bill, collect, and recognize revenue for provider services. The AVP leads a multi-site or system-level team responsible for primary source verification, medical staff credentialing and reappointment, delegated and non-delegated payer enrollment, CAQH and provider database integrity, and ongoing regulatory compliance with NCQA, CMS, Joint Commission, and state-specific requirements. This individual serves as the organization's subject matter expert on credentialing and enrollment matters, advising senior executives, Medical Staff leadership, and Payer Relations & Contracting on the operational and compliance implications of growth, Mergers & Acquisitions (M & A), network changes, and payer relationships. This is a highly visible leadership role with significant cross-functional reach, requiring close collaboration with Payer Relations & Contracting, Revenue Cycle, Physician Recruitment, Medical Staff Services, Compliance, Legal, and Finance. The AVP is expected to bring both strategic judgment and hands-on operational expertise to a function with direct, measurable revenue impact. Minimum Qualifications Education, Certification, and/or Licensure: 1. Bachelor's degree in health care administration or a related field of study or seven (7) years of relevant work experience. Experience:

1. Twelve (12+) years of progressive experience in provider credentialing, medical staff services, and/or payer enrollment, including at least five to eight (5-8) years in a leadership/management capacity.
2. Demonstrated experience with NCQA, CMS, and Joint Commission standards as they relate to credentialing.
3. Experience overseeing delegated and non-delegated payer enrollment processes at a payer, multi-facility or system level.
4. Demonstrated success leading through a Joint Commission or NCQA survey cycle.
5. Proven people-leadership experience, including managing directors, managers and building team capability.
6. Working knowledge of credentialing/enrollment platforms (e.g., CAQH, PECOS, NPPES, CredentialStream).

Preferred Qualifications Education, Certification, and/or Licensure:

1. Advanced degree in Healthcare Administration (MHA), Business Administration (MBA), or a related field of study preferred.
2. Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM) through NAMSS

Experience:

1. Experience at an academic medical center or large multi-hospital health system ($5B+ net revenue).
2. Experience supporting M & A integration, consent-to-assign analysis, or large-scale network consolidation from a credentialing/enrollment perspective.
3. Experience with Physician-Hospital Organization (PHO) governance, delegated credentialing agreements, and PHO-level payer enrollment Familiarity with revenue cycle metrics and the financial impact of enrollment turnaround time on clean-claim rate and days in A/R Experience implementing workflow automation within a credentialing/enrollment function.

Core Duties and Responsibilities The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Develop and execute the system's strategy for provider credentialing and payer enrollment, ensuring alignment with organizational growth, M & A activity, and network expansion plans.
2. Support the VP & Chief Managed Care Officer in department budget, staffing model, and productivity benchmarks; identify and close staffing or workflow gaps relative to best-practice standards.
3. Lead, develop, and retain multi-tiered team of directors, managers, supervisors, and credentialing/enrollment specialists; build leadership bench strength.
4. Drive automation and technology adoption to improve scalability, turnaround time, and data accuracy.
5. Oversee initial credentialing, reappointment, privileging, and Focused/Ongoing Professional Practice Evaluation (FPPE/OPPE) processes in partnership with Medical Staff leadership.
6. Ensure credentialing files, bylaws, and processes meet NCQA, Joint Commission, CMS, and state regulatory standards; lead survey readiness and serve as a key resource during accreditation surveys.
7. Maintain delegated credentialing agreements.
8. Oversee end-to-end payer enrollment operations across Medicare, Medicaid, and commercial payers, including CAQH attestation, NPI/PECOS maintenance, and roster management.
9. Serve as subject matter expert on payer enrollment matters affecting business development, market expansion, M & A integration, new delegation agreements, consent-to-assign, or contract-novation scenarios.
10. Minimize revenue leakage from enrollment delays by setting and monitoring turnaround-time targets and escalation pathways.
11. Oversee credentialing and payer enrollment for providers participating in the system's Physician-Hospital Organization (PHO), including employed, independent, and affiliated practice participants.
12. Maintain compliance with PHO governance, bylaws, and participation agreements as they relate to credentialing standards and payer enrollment eligibility.
13. Serve as the primary point of escalation for PHO-related credentialing or enrollment discrepancies affecting claims submission or payer directory accuracy.
14. Partner with Payer Relations & Contracting, Revenue Cycle, and Finance to ensure enrollment and credentialing timelines support clean-claim submission and minimize denial/write-off exposure.
15. Advise the Chief Revenue Cycle Officer, Chief Financial Officers, and other senior executive on credentialing/enrollment risk and readiness related to new service lines, acquisitions, and payer market changes.
16. Partner with Physician Recruitment to streamline provider onboarding timelines.
17. Ensure full compliance with HIPAA, False Claims Act, Anti-Kickback Statute, and payer-specific administrative requirements as they relate to provider data and enrollment.
18. Maintain confidentiality of sensitive provider information in accordance with regulatory and organizational policy.
19. Oversee vendor relations (CVOs, credentialing software vendors) including contract performance and Service Level Agreement management.
20. Establish and maintain relationships with payers, HMOs, and other organizations essential to maintaining the PHO network, and conducting CMSO business.

Physical Requirements: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Capable of prolonged periods of standing and walking. Working Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 1. Standard office environment. Skills and Abilities: Executive presence and the ability to translate complex regulatory and operational detail into clear, decision-ready information for C-suite and Medical Staff leadership. Strong independent judgment in interpreting and applying NCQA, Joint Commission, URAC, CMS, and state regulatory requirements. High-level relationship management across physicians, payers, market/site leaders, and senior executives. Advanced organization and project management skills, with the ability to manage multiple concurrent priorities and competing deadlines across sites. Analytical aptitude to assess staffing models, productivity benchmarks, and turnaround-time data, and translate findings into action. Skilled at developing and coaching, with a track record of building succession depth on a team. Sound, practical approach to ambiguity and problem-solving in a highly regulated, fast-changing environment Additional Job Description: Scheduled Weekly Hours: 40 Shift: Exempt/Non-Exempt: United States of America (Exempt) Company: SYSTEM West Virginia University Health System Cost Center: 500 PHH Administration Address: 1085 Van Voorhis Rd Morgantown West Virginia Equal Opportunity Employer West Virginia University Health System and its subsidiaries (collectively "WVUHS") is an equal opportunity employer and complies with all applicable federal, state, and local fair employment practices laws. WVUHS strictly prohibits and does not tolerate discrimination against employees, applicants, or any other covered persons because of race, color, religion, creed, national origin or ancestry, ethnicity, sex ( WVU Medicine