Senior Credentialing & Compliance Lead

BrightonOne; Boston (MA); Hybrid; USD 70,000 - 100,000; Full time

Job summary

BrightonOne in Boston, MA is seeking a Senior Credentialing Specialist to lead USFHP provider credentialing and recredentialing operations, ensuring regulatory and accreditation standards are met. The role manages the credentialing process end to end—from intake and primary source verification to committee preparation and ongoing monitoring—to maintain a compliant, audit-ready network.

The position requires a Bachelor's degree (or equivalent experience), 4+ years in provider credentialing, and

Qualifications

• Bachelor's degree preferred, or equivalent experience.
• 4+ years of provider credentialing experience in managed care or a health plan.
• Experience with NCQA/URAC credentialing standards; CPCS or CPMSM certification preferred.

Responsibilities

• Manage initial credentialing and recredentialing end to end, including application intake (e.g., CAQH), primary source verification (license, education, board certification, work history, malpractice), and file preparation.
• Ensure compliance with NCQA/URAC credentialing standards, TRICARE/USFHP, DHA, and State regulatory requirements and turnaround times.
• Prepare and present clean and adverse files to the credentialing committee; document decisions and maintain accurate records.
• Ensure that approved credentials are quickly provided to the Provider Data Management function.
• Perform ongoing monitoring of licensure, sanctions, and exclusions (e.g., OIG, SAM, OFAC, NPDB, state license boards) and elevate findings to the appropriate committee or clinical reviewer(s).
• Track and manage expirables (license, DEA, malpractice, board certification) and provider data updates.
• Maintain audit-ready documentation; support accreditation and regulatory audits and file reviews.
• Drive credentialing process improvement, accuracy, and turnaround-time performance.
• Partner with provider data, network, and compliance teams; guide or mentor credentialing staff as needed.

Skills

Credentialing standards

Primary source verification

Regulatory compliance

CAQH / credentialing systems

NPDB/exclusion sources

TRICARE / USFHP knowledge

Education

Bachelor's degree preferred

Job description

BrightonOne in Boston, MA is seeking a Senior Credentialing Specialist to lead USFHP provider credentialing and recredentialing operations, ensuring regulatory and accreditation standards are met. The role manages the credentialing process end to end—from intake and primary source verification to committee preparation and ongoing monitoring—to maintain a compliant, audit-ready network.

The position requires a Bachelor's degree (or equivalent experience), 4+ years in provider credentialing, and