Administrative - Credentialing Specialist (Days)

Job Description

Job Description

Job Title: Credentialing Analyst (Health Plan / Managed Care)

Job Summary: We are seeking a detail-oriented and analytical

Credentialing Analyst to support managed care credentialing programs in compliance with federal, state, and NCQA accreditation requirements. In this role, you will evaluate healthcare practitioners and facilities upon network entry, conduct ongoing provider reviews, oversee delegated/non-delegated provider data, and maintain accurate provider directory metrics. This position offers fully remote flexibility for qualified candidates residing within the state.

Compensation & Work Environment:

• Location Eligibility: Must reside within the state of Texas [Required]
• Work Setup: Remote work available (requires high-speed internet, secure workspace, and a multi-monitor desktop setup)

Key Responsibilities:

• Provider Evaluation & Credentialing: Verify and process initial credentialing and re-credentialing applications for practitioners and facilities to ensure compliance with NCQA and regulatory standards.
• Data Analysis & Reporting: Gather, analyze, and track provider data for directory updates, billing setup, and internal reporting using advanced spreadsheet tools and database portals.
• Delegated Oversight & Auditing: Assist with oversight audits of delegated and non-delegated provider groups; identify data discrepancies, and recommend process improvements.
• External Partner Coordination: Interface with credentialing databases and partner organizations to streamline application processing and resolve provider inquiries.
• Confidentiality & Compliance: Maintain strict confidentiality regarding provider credentials and personal information while adhering to state and organizational credentialing policies.

Qualifications & Requirements:

• Experience: Minimum 3+ years of managed care or credentialing analyst experience [Required] .
• Education: Bachelor’s degree in Healthcare, Business, or Health Administration [Required] .
• Software Proficiency: Advanced skills in Microsoft Excel (VLOOKUP, complex formulas/functions), Adobe Pro, Microsoft Outlook, and SharePoint [Required] .
• Industry Portals & Accreditation: Prior experience with CAQH, TAHP, NCQA accreditation, Aperture, or the National Provider Data Bank (NPDB) [Highly Preferred] .
• Certifications: National Association Medical Staff Services (NAMSS) certification (CPCS or CPMSM) [Highly Preferred] .
• Regulatory Knowledge: Familiarity with managed care statutes and provider data management practices [Highly Preferred] .
• Core Competencies: Exceptional analytical skills, strong problem-solving initiative, and clear verbal/written communication abilities.