Credentialing Specialist

About the role

The Credentialing Specialist supports the provider credentialing process by reviewing applications, maintaining accurate credentialing records, communicating with providers, and ensuring credentialing activities meet company, federal, state, and regulatory requirements. This role partners closely with internal departments and external stakeholders to support timely, accurate, and compliant provider onboarding and ongoing credentialing operations.

Responsibilities

• Coordinate and maintain credentialing activities, including reviewing applications and supporting documentation for completeness, accuracy, to ensure compliance with applicable regulations.
• Communicate with providers regarding application status, missing or incomplete information, credentialing requirements, and next steps.
• Obtain, review, and evaluate practitioner sanctions, complaints, adverse actions, and other credentialing-related data to support compliant decision-making.
• Maintain accurate, complete, and confidential credentialing documentation, including sensitive background information, in accordance with company policies and federal, state, and regulatory requirements.
• Compile, evaluate, and prepare provider-specific information for Credentials Committee review, and track related follow-up items, including notifications, appeals, hearing processes, and post-committee actions.
• Partner with internal departments to support provider contracting, quality-related activities, remedial action plans, reporting requirements, and ongoing process improvements.
• Draft and maintain policies, procedures, workflows, and processes to support operational effectiveness, regulatory compliance, and achievement of department metrics and service-level expectations.
• Participate in the formation and facilitation of Credentials Committee processes and workflows.
• Support delegation oversight activities, including delegation setup, onboarding of new delegated partners, oversight of delegated credentialing activities, and ongoing monitoring to ensure delegated entities remain compliant with applicable regulations, company requirements, and delegation agreements.
• Participate in or conduct credentialing site visits, report adverse credentialing actions to appropriate agencies, and prepare documentation or reports for audits requested by regulatory or accrediting bodies, as applicable.
• Build and maintain productive, cooperative working relationships with providers, peers, management, and internal and external stakeholders.

Requirements

This is an onsite role located at our Meridian, Idaho campus and will offer a hybrid work schedule. We're looking for a Credentialing Specialist with experience in a health care industry setting, such as billing, credentialing, provider enrollment, or a state medical regulatory agency. Education: High School or equivalent. Preferred Qualifications: One year of experience in provider credentialing. Experience supporting or performing delegation oversight activities. Proficiency with data reporting tools, queries, and Microsoft Excel to support tracking, analysis, and operational reporting.

Qualifications

Two years of experience in a health care industry setting, such as billing, credentialing, provider enrollment, or a state medical regulatory agency.

Skills

Experience supporting or performing delegation oversight activities. Proficiency with data reporting tools, queries, and Microsoft Excel to support tracking, analysis, and operational reporting.

Benefits

At Blue Cross of Idaho, we offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program. We also adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.

Pay

As of the date of this posting, a good faith estimate of the current pay range is $21.39 - $29.95. The position is eligible for an annual incentive bonus (variable depending on company and employee performance).

Schedule

The role offers a hybrid work schedule.