Credentialing Professional

Humana Inc; Wisconsin; Hybrid; USD 59,000 - 70,000; Full time

Job summary

Humana Inc. is seeking a Credentialing Specialist to manage credentialing and recredentialing for providers serving the Wisconsin Medicaid market.

You will maintain accurate provider records, support audits, ensure compliance with NCQA, DHS and CMS requirements, and coordinate with multiple internal departments and external vendors. The role emphasizes quality data, timely workflows, and collaboration across network development, provider relations, and compliance.

Qualifications

• Associates degree or Certified Provider Credentialing Specialist certification.
• 3+ years in credentialing and recredentialing.
• 2 years using Adobe and Microsoft applications.
• 1 year in audit prep, file reviews, and identifying deficiencies.
• Understanding of NCQA, DHS and CMS regulations.
• Mon-Fri 8:30-17:00 CST.

Responsibilities

• Credentialing operations: initial and recredentialing for practitioners and organizational providers.
• Compliance oversight: NCQA, Medicaid, DHS, CMS and internal policy alignment.
• Quality and auditing: maintain credentialing records and support audits.
• Provider data and network integrity: keep records accurate and monitor requirements.
• Workflows: monitor turnaround times and drive process improvements.
• Coordination: collaborate with networks, contracting, compliance and external vendors.

Skills

Credentialing

Recredentialing

NCQA knowledge

Microsoft Office

Education

Associates degree

Certified Provider Credentialing Specialist

Tools

Adobe

Microsoft 365

Job description

Become a part of our caring community If you're someone who loves details, organization, and making sure everything is just right, this could be the role for you! You will keep our provider network running smoothly. You will manage credentialing and recredentialing, maintain accurate provider records, support compliance and audits, and improve the way we work. Reporting to the Credentialing Supervisor, you will be a part of a dynamic team supporting the WI Medicaid Market.

Main Responsibilities

• Credentialing Operations: Performing initial and recredentialing for practitioners and organizational providers following established requirements.
• Compliance and Regulatory Oversight: Ensure credentialing activities meet NCQA, state Medicaid, DHS, CMS and internal policy requirements.
• Quality and Auditing: Maintain complete, accurate credentialing records and support audits and file reviews.
• Provider Data and Network Integrity: Maintain accurate provider records, monitor ongoing credentialing requirements, and coordinate provider and practitioner status changes with appropriate departments.
• Workflows: Monitor credentialing turnaround time, resolve discrepancies, and contribute to process improvement.
• Provider and Internal Department Coordination: Colloborate with network development, provider relations, contracting, compliance and external credentialing vendors to resolve discrepancies to ensure providers meet participation requirements.

Required Qualifications

• Associates degree or have a Certified Provider Credentialing Specialist certification
• 3 or more years of experience in credentialing and recredentialing
• 2 years of experience working in Adobe and Microsoft applications
• 1 year of experience with audit preparation, file reviews, and identifying documentation deficiencies
• Understanding of NCQA requirements, DHS and CMS regulations
• Work between 8:30-5:00pm CST, Monday through Friday

Preferred Qualifications

• Bachelor's Degree in Business or a related field
• Reside in WI
• Knowledge of state regulations on compliance in the insurance industry
• Managed Care Organization experience
• Advanced experience working with NCQA standards
• Experience working with governmental agencies

Additional Information

Additional Information Workstyle: Home Work Days/Hours: Monday – Friday, 8:30 am – 5:00 pm Central Standard Time (CST) Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information. Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours 40 Pay Range

Scheduled Weekly Hours 40 Pay Range The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc. $58,700 - $70,400 per year This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

About us

About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer atHumana.comand atCenterWell.com.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.