Credentialing & Enrollment Specialist

Avera Health; Sioux Falls (SD); On-site; USD 63,039,000 - 84,530,000; Full time

Benefits offered by this job

PTO available day 1

5% retirement matching

Career development & mentorship

Job summary

Avera Health Plans is seeking a Credentialing Operations Specialist to coordinate provider credentialing in line with NCQA, state, and federal requirements. You will review applications, coordinate enrollment for contracted providers, and ensure timely, compliant communication and data entry across systems.

Responsibilities include PSV verification, Medical Director coordination, and monthly credentialing file preparation, with emphasis on accuracy and regulatory compliance.

Qualifications

• Associate’s degree or equivalent required.
• 1–3 years credentialing, enrollment or related admin experience.
• Bachelor’s degree preferred in health information or related field.
• NAMSS CPCS or CPMSM certification preferred.

Responsibilities

• Know NCQA credentialing standards and applicable laws and apply to process.
• Coordinate initial enrollment and re-enrollment for contracted providers/facilities.
• Review credentialing apps for NCQA compliance and collect missing information.
• Review PSV checks from CVO and document clean vs red flag status.
• Coordinate file review with Medical Director and gather required info.
• Assist in monthly Credentialing Committee file prep.
• Send compliant communications to providers about terminations, denials, approvals.
• Enter data and maintain enrollment records in credentialing systems.
• Respond to applicants/providers regarding credentialing process and status.
• Serve as a resource, conduct audits, and prepare files for audits.

Skills

NCQA knowledge

Credentialing

Enrollment processes

Effective communication

Education

Associate degree

Bachelor’s in related field

CPCS or CPMSM (preferred)

Tools

Credentialing system

Job description

Avera Health Plans is seeking a Credentialing Operations Specialist to coordinate provider credentialing in line with NCQA, state, and federal requirements. You will review applications, coordinate enrollment for contracted providers, and ensure timely, compliant communication and data entry across systems.

Responsibilities include PSV verification, Medical Director coordination, and monthly credentialing file preparation, with emphasis on accuracy and regulatory compliance.