Health Plan Credentialing Specialist

Western Health Advantage; Sacramento (CA); Híbrido; USD 70.000 - 85.000; Jornada completa

Descripción de la vacante

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

Formación

• 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.

Responsabilidades

• 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.

Conocimientos

Organizational skills

Analytical skills

Communication skills

Presentation skills

Educación

Bachelor’s degree in healthcare-related field

Descripción del empleo

Western Health Advantage
Location: Sacramento, CA (Hybrid)
Salary: $70,304–$85,000 annually
\"Purpose that inspires. Impact that improves lives. Join us in building healthier communities.\"
Western Health Advantage

Strengthen Quality. Support Advance Credentialing Excellence.

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 position leads credentialing oversight activities and helps ensure compliance with National Committee for Quality Assurance (NCQA) accreditation standards and California Department of Managed Health Care (DMHC) regulatory requirements.

The Credentialing Specialist works closely with internal leadership, Medical Management staff, delegated medical groups, and Independent Practice Associations (IPAs) to promote regulatory readiness, operational excellence, and continuous quality improvement.

What You’ll Do

• Lead the Credentialing Program and ensure ongoing compliance with accreditation and regulatory standards.
• Maintain credentialing policies and procedures and oversee delegated credentialing activities.
• Conduct annual credentialing file reviews, delegate audits, monitoring activities, and corrective action follow-up.
• Educate delegated entities on credentialing requirements and present findings and reports to applicable committees.
• Participate in Health Industry Collaboration Effort (HICE) activities, including onsite medical group audits, inter-rater reliability audits, and monthly and quarterly meetings.
• Coordinate Credentialing Committee meetings, materials, reporting, and follow-up activities.
• Conduct annual reviews of delegated credentialing policies and procedures.
• Support expansion activities, pre-delegation audits, and policy and procedure reviews.
• Partner with the Chief Medical Officer, Corporate Quality Director, and Quality Improvement team to develop and update program documents, policies, reports, committee presentations, Quality Improvement Projects, and focused studies.
• Perform internal and external monitoring and oversight activities and provide feedback or training in response to findings.
• Serve as a member of the Quality Improvement Committee.
• Support NCQA accreditation and DMHC survey readiness, including document preparation, onsite reviews, and post-survey follow-up.
• Manage multiple projects and workflows to ensure requirements and reporting deadlines are met.
• Perform additional duties and special projects as assigned.

What You’ll Bring

• Bachelor’s degree in a healthcare-related field preferred.
• At least four years of experience working with NCQA credentialing oversight.
• Certified Provider Credentialing Specialist (CPCS) certification preferred; certification must be obtained within two to three years of employment.
• Previous healthcare industry experience; experience working for an HMO is a plus.
• Strong knowledge of credentialing standards, delegated oversight, audits, monitoring, and regulatory requirements.
• Excellent organizational, analytical, communication, and presentation skills.
• Ability to manage competing priorities and meet established deadlines.
• Proficiency with email, databases, word-processing, spreadsheet, presentation, and related business applications.
• Ability to speak, read, write, and understand the primary language used in the workplace.

Equal Employment Opportunity

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.

Western Health Advantage values and supports the unique talents and strengths each employee brings to our organization. Collaborating with the best and brightest means a dynamic, fulfilling work experience for you—and excellent customer service for our members.