Credentialing Specialist

Western Health Advantage Location: Sacramento, CA (Hybrid) Salary: $70,000–$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 standardsMaintain credentialing policies and procedures and oversee delegated credentialing activitiesConduct annual credentialing file reviews, delegate audits, monitoring activities, and corrective action follow-upEducate delegated entities on credentialing requirements and present findings and reports to applicable committeesParticipate in Health Industry Collaboration Effort (HICE) activities, including onsite medical group audits, inter-rater reliability audits, and monthly and quarterly meetingsCoordinate Credentialing Committee meetings, materials, reporting, and follow-up activitiesConduct annual reviews of delegated credentialing policies and proceduresSupport expansion activities, pre-delegation audits, and policy and procedure reviewsPartner 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 studiesPerform internal and external monitoring and oversight activities and provide feedback or training in response to findingsServe as a member of the Quality Improvement CommitteeSupport NCQA accreditation and DMHC survey readiness, including document preparation, onsite reviews, and post-survey follow-upManage multiple projects and workflows to ensure requirements and reporting deadlines are metPerform additional duties and special projects as assigned What You’ll Bring Bachelor’s degree in a healthcare-related field preferredAt least four years of experience working with NCQA credentialing oversightCertified Provider Credentialing Specialist (CPCS) certification preferred; certification must be obtained within two to three years of employmentPrevious healthcare industry experience; experience working for an HMO is a plusStrong knowledge of credentialing standards, delegated oversight, audits, monitoring, and regulatory requirementsExcellent organizational, analytical, communication, and presentation skillsAbility to manage competing priorities and meet established deadlinesProficiency with email, databases, word-processing, spreadsheet, presentation, and related business applicationsAbility 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. Powered by JazzHR cvbTVvz1VZ