NCQA & DMHC Credentialing Specialist

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

Job summary

Western Health Advantage in Sacramento, CA is seeking a Credentialing Specialist to support the Quality Management team in achieving NCQA accreditation and DMHC regulatory goals. The role leads credentialing oversight, promotes regulatory readiness, and collaborates with Medical Management, IPAs, and delegated groups to improve quality and compliance.

Qualified candidates have 4+ years in NCQA credentialing and a bachelor's degree in a healthcare field; CPCS is preferred and should be obtained

Qualifications

• At least four years of NCQA credentialing oversight experience.
• CPCS certification preferred; to be obtained within 2–3 years of employment.
• Experience working for an HMO is a plus.
• Strong knowledge of credentialing standards, audits, monitoring, and regulatory requirements.

Responsibilities

• Lead credentialing program and ensure ongoing compliance with accreditation standards.
• Maintain credentialing policies and oversee delegated credentialing activities.
• Conduct annual credentialing file reviews and audits with follow-up on corrective actions.
• Educate delegated entities on credentialing requirements and present findings to committees.
• Coordinate credentialing committee meetings, materials and reporting.
• Support NCQA accreditation and DMHC survey readiness, including documentation and onsite reviews.
• Manage multiple projects and ensure reporting deadlines are met.
• Perform internal monitoring and provide training in response to findings.

Skills

Organizational skills

Analytical skills

Communication

Presentation skills

Education

Bachelor’s degree in healthcare

Job description

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.