Credentialing Program Lead - Health Plan Compliance & Quality

Western Health Advantage; Sacramento (CA); Hybrid; USD 70,000 - 85,000; Full time

Job summary

Western Health Advantage is seeking an experienced Credentialing Specialist to support our Quality Management team in achieving the organization’s Quality Improvement and Credentialing Program goals. This role leads credentialing oversight activities to ensure NCQA accreditation readiness and DMHC regulatory compliance.

You will collaborate with Medical Management, delegated groups, and IPAs to promote regulatory readiness and continuous quality improvement while supporting audits, policy

Qualifications

• Bachelor’s degree in a healthcare-related field.
• At least four years of NCQA credentialing oversight experience.
• CPCS certification preferred; must be obtained within 2–3 years of employment.
• Healthcare industry experience; HMO experience a plus.
• Strong knowledge of credentialing standards, delegated oversight, audits and regulatory requirements.
• Excellent organizational, analytical, communication, and presentation skills.
• Ability to manage competing priorities and meet deadlines.
• Proficient with email, databases, word processing, spreadsheets, presentations.

Responsibilities

• Lead Credentialing Program and ensure ongoing compliance with accreditation and regulatory standards.
• Maintain credentialing policies and oversee delegated credentialing activities.
• Conduct annual credentialing file reviews, audits, monitoring activities, and corrective action follow-ups.
• Educate delegated entities on credentialing requirements and present findings to committees.
• Coordinate credentialing committee meetings, materials, reporting, and follow-up.

Skills

Organizational skills

Analytical skills

Communication skills

Presentation skills

Education

Bachelor’s degree in healthcare-related field

Job description

Western Health Advantage is seeking an experienced Credentialing Specialist to support our Quality Management team in achieving the organization’s Quality Improvement and Credentialing Program goals. This role leads credentialing oversight activities to ensure NCQA accreditation readiness and DMHC regulatory compliance.

You will collaborate with Medical Management, delegated groups, and IPAs to promote regulatory readiness and continuous quality improvement while supporting audits, policy