Credentialing Operations 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

Location:

Avera Health Plans

Worker Type:

Regular

Work Shift:

Primarily days with possible weekends/evenings/holidays (United States of America)

Pay Range:

The pay range for this position is listed below. Actual pay rate dependent upon experience.

$22.00 - $29.50

Position Highlights

You Belong at Avera

Be part of a multidisciplinary team built with compassion and the goal of Moving Health Forward for you and our patients. Work where you matter.

A Brief Overview

The Credentialing Operations Specialist is responsible for coordinating provider credentialing and enrollment activities in compliance with NCQA, state, and federal requirements. Reviews applications for accuracy and completeness, partners with providers and internal teams to resolve issues, and prepares files for Medical Director and committee review. Maintains credentialing data, supports audits, and ensures timely, compliant communication regarding provider status.

What you will do

• Knowledge of NCQA Credentialing standards and all applicable state and government laws regarding credentialing and applies them to the credentialing process.
• Coordinates the initial enrollment and re-enrollment process for providers and facilities contracted with Avera Health Plans.
• Reviews initial and reappointment credentialing applications to ensure compliance with NCQA process. Ensures application completeness and works with providers to gather missing or incomplete information.
• Reviews credentialing applications returned from the Central Verification Organization (CVO) to ensure Primary Source Verifications (PSV) were done accurately and timely, consistent with NCQA, state and federal credentialing requirements. Accurately determines and documents clean vs red flag files.
• Coordinates with Medical Director for file review of clean and red flag files. Gathers additional information based on the Medical Directors feedback.
• Assists in monthly Credentialing Committee File preparation.
• Generates and sends out compliant communication to providers related to credentialing terminations, denials, and approvals consistent with Avera Health Plans policies and NCQA requirements.
• Performs accurate data entry and maintains enrollment records within the credentialing system and internal databases.
• Responds to applicants and current providers regarding the credentialing process and status.
• Serves as a resource to internal and external clients by answering credentialing questions, conducting audits, and doing file preparation for audits.

Essential Qualifications

The individual must be able to work the hours specified. To perform this job successfully, an individual must be able to perform each essential job function satisfactorily including having visual acuity adequate to perform position duties and the ability to communicate effectively with others, hear, understand and distinguish speech and other sounds. These requirements and those listed above are representative of the knowledge, skills, and abilities required to perform the essential job functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions, as long as the accommodations do not cause undue hardship to the employer.

Required Education, License/Certification, or Work Experience:

• Associate’s Two-year college or technical school or an equivalent combination of education and experience.
• 1-3 years Credentialing experience, provider enrollment, provider contracting, compliance, advanced medical or administrative experience and/or training.

Preferred Education, License/Certification, or Work Experience:

• Bachelor’s In a related field of health information/healthcare or business.
• Certified Provider Credentialing Specialist (CPCS) - National Association of Medical Staff Services (NAMSS) or
• Certified Professional Medical Services Management (CPMSM) - National Association of Medical Staff Services (NAMSS)

Expectations and Standards

• Commitment to the daily application of Avera’s mission, vision, core values, and social principles to serve patients, their families, and our community.
• Promote Avera’s values of compassion, hospitality, and stewardship.
• Uphold Avera’s standards of Communication, Attitude, Responsiveness, and Engagement (CARE) with enthusiasm and sincerity.
• Maintain confidentiality.
• Work effectively in a team environment, coordinating work flow with other team members and ensuring a productive and efficient environment.
• Comply with safety principles, laws, regulations, and standards associated with, but not limited to, CMS, The Joint Commission, DHHS, and OSHA if applicable.

Benefits You Need & Then Some

Avera is proud to offer a wide range of benefits to qualifying part‑time and full‑time employees. We support you with opportunities to help live balanced, healthy lives. Benefits are designed to meet needs of today and into the future.

• PTO available day 1 for eligible hires.
• Up to 5% employer matching contribution for retirement
• Career development guided by hands‑on training and mentorship

Avera is an Equal Opportunity Employer - Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, Veteran Status, or other categories protected by law. If you are an individual with a disability and would like to request an accommodation for help with your online application, please call 1-605-504-4444 or send an email to [e-mail].