Provider Credentialing Rep

About the role

The Provider Credentialing Representative oversees complex certification and credentialing activities, leading the review and evaluation of processes to identify gaps, redundancies, and improvement opportunities. This role facilitates meetings to resolve certification and credentialing issues, manages the Credentialing shared inbox, and collaborates with Credentialing department leaders to refine processes.

Responsibilities

• Ensures credentialing and certification activities adhere to regulatory requirements, accreditation criteria, federal program guidelines, and internal quality standards.
• Serves as an internal resource and subject-matter expert on credentialing policies, workflows, systems, and best practices; provides guidance to team members and cross-functional partners as needed.
• Manages the credentialing shared inbox, ensuring triage, prioritization, and resolution of incoming requests, inquiries, and escalations within established service-level expectations.
• Makes sure certification and credentialing escalations are timely, accurate, and compliant; initiates follow-up actions and coordinates cross-functional support as needed.
• Facilitates and coordinates meetings with internal departments and external stakeholders to address certification and credentialing issues, concerns, or process dependencies; documents outcomes and drives execution of agreed-upon action items.
• Supports the development, review, and ongoing maintenance of provider communication materials, including notices, guides, templates, and FAQs.
• Aids in developing, compiling, and distributing routine and ad hoc reports on certification and credentialing metrics, KPIs, backlog trends, workflow timeliness, and quality indicators; contributes to presenting findings to leadership and recommending improvement strategies.
• Collaborates with internal teams to validate system updates, contributes to process documentation, and assists in readiness efforts for audits or accreditation reviews.
• Participates in or leads special projects, workflow assessments, and operational initiatives focused on enhancing credentialing efficiency, provider experience, and organizational compliance.

Requirements

• High School Diploma or GED
• 2+ years of provider credentialing experience
• 2+ years of experience working with credentialing applications and provider data management systems to support end-to-end credentialing and data workflows
• Working knowledge of URAC and/or NCQA standards, as well as VA, TRICARE, or other federal program requirements
• If supporting TRICARE contract, must be a U.S. Citizen
• If supporting TRICARE contract, must be able to receive a favorable interim and adjudicated final Department of Defense (DoD) background investigation

Preferred

• 3+ years of provider credentialing experience
• 3+ years of experience working with credentialing applications and provider data management systems to support end-to-end credentialing and data workflows

Qualifications

• Current and applied knowledge of URAC standards, VA CCN and TRICARE regulations and requirements, as well as medical terminology
• Current and applied knowledge of delegated credentialing processes
• Proficient with credentialing software and provider data management systems
• Proficient with Microsoft applications (Outlook, Teams, Word, Excel, PowerPoint, and SharePoint)

Skills

• Communication / People Skills
• Coping / Flexibility
• Computer Literacy
• Empathy / Customer Service
• Independent Thinking / Self-Initiative
• Information Management
• Organizational Skills
• Problem Solving / Analysis
• Technical Skills

Benefits

We offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

Salary range: Around $49,000 to $52,000 per year.

Company Overview

We are dedicated to serving America's heroes and making sure they get connected to healthcare in their communities. We strive to create an inclusive environment that supports diversity at every level and offer a variety of benefits and opportunities for growth.