Senior Credentialing Specialist

Senior Credentialing Specialist

The Senior Credentialing Specialist leads USFHP's provider credentialing and recredentialing operations, ensuring providers meet regulatory and accreditation standards. This role manages the credentialing process end to end — application intake, primary source verification, committee preparation and participation, and ongoing monitoring — ensuring timely, accurate, compliant, audit-ready credentialing that safeguards network integrity and member safety.

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 escalate 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.

Support delegated-credentialing oversight and perform required review and audit of Delegates where applicable.

Drive credentialing process improvement, accuracy, and turnaround-time performance.

Partner with provider data, network, and compliance teams; guide or mentor credentialing staff as needed.

Bachelor's degree preferred, or equivalent experience.

4 or more years of provider credentialing experience in managed care or a health plan.

Experience with NCQA/URAC credentialing standards; CPCS or CPMSM certification preferred.

Deep knowledge of credentialing standards, primary source verification, and regulatory requirements.

Strong attention to detail, organization, and audit readiness.

Proficiency with credentialing systems/databases and CAQH; knowledge of NPDB and exclusion sources.

Familiarity with TRICARE/USFHP preferred.

Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.

Some elements of the job are sedentary, but the employee will be required to stand for periods of time or move throughout the campus.

BrightonOne is an Equal Opportunity Employer. We prohibit discrimination and harassment of any kind based on race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, age, disability, genetic information, protected veteran status, or any other characteristic protected by federal, state, or local law. We strongly encourage applications from veterans and individuals with disabilities. Accommodations are available upon request for candidates taking part in all aspects of the selection process.

Candidates must be authorized to work in the United States without sponsorship now or in the future.