Calpion Software Technologies - Director - Credentialing - Revenue Cycle Management

Job Title: Director - Credentialing (RCM)

Location: Bangalore, India

Experience: 15-20 Years.

Reports To: VP - Operations / Head of RCM

Role Summary:

- The Director of Credentialing is a strategic leadership role responsible for the end-to-end provider enrolment and credentialing lifecycle. At Calpion, you will lead a large-scale offshore team to ensure healthcare providers are accurately and timely credentialed with US insurance payers (Medicare, Medicaid, and Commercial).

- You will be a key driver in integrating Calpion's AI and RPA capabilities to automate credentialing workflows, directly impacting the organization's clean claim rate and revenue flow.

Key Responsibilities:

1. Strategic Operations & AI Integration:

- Workflow Optimization: Define and implement standardized processes for provider onboarding, recredentialing, and Primary Source Verification (PSV).

- Automation Leadership: Collaborate with the technology team to deploy RPA bots for manual tasks like CAQH updates, license monitoring, and application tracking.

- Centre of Excellence (CoE): Establish a CoE for Credentialing to drive best practices across multiple healthcare specialties and US states.

2. Performance & Client Delivery:

- KPI Management: Monitor and exceed critical metrics, including Turnaround Time (TAT) for enrolments, Denial Rates related to credentialing, and provider satisfaction.

- SLA Compliance: Ensure 100% adherence to client Service Level Agreements (SLAs) and internal quality benchmarks.

- Payer Relations: Navigate complex payer "closed panels" and maintain relationships with major US payers to expedite provider enrolments.

3. Team Leadership & Governance:

- Resource Planning: Manage capacity planning and forecasting for a large-scale team (100+ members).

- Compliance: Ensure 100% adherence to HIPAA regulations, ISO standards, and NCQA/Joint Commission guidelines.

- Training & Mentorship: Foster professional growth by mentoring managers and leads on complex US healthcare regulations and state-specific mandates.

4. Financial Oversight

- P&L Management: Manage the department's budget and operational costs to meet Gross/Net Margin goals.

- Revenue Protection: Identify and mitigate "credentialing-related revenue leakage" by resolving bottlenecks that cause claim rejections.

Mandatory Skills & Qualifications:

- Experience: 15+ years in US Healthcare RCM, with at least 7+ years in a senior leadership role (Director/AGM/GM).

- Domain Expertise: Mastery of CAQH, PECOS, NPI (NPPES), and end-to-end provider enrollment with US Federal and Commercial payers.

- Technical Savvy: Experience with RCM platforms (Epic, Athena, NextGen) and a strong understanding of how AI/RPA can be applied to credentialing.

- Communication: Exceptional negotiation and presentation skills for interacting with US-based stakeholders and C-suite leadership.

- Education: Bachelor's degree in any field (master's in healthcare management or MBA preferred).

Desired Skills:

- Certifications: CPCS (Certified Provider Credentialing Specialist) or CPMSM is a plus

- Methodologies: Six Sigma or Lean certification for process improvement.

- Team Size: Proven experience managing a department of 200+ employees.