Credentialing Specialist

Position Title Credentialing Specialist Job Type Regular, Full-Time, Non-Exempt, Non-Union, Benefitted Reporting Relationship Program Director Summary Since its founding as a teen drop-in center in 1972, Community Solutions (CS) has grown in both depth and breadth of services in response to the growing and changing needs in the community. As one of the most comprehensive nonprofit human services agencies in Santa Clara County and the surrounding areas, CS provides prevention, intervention, treatment, and residential services to more than 6,400 clients annually, helping them overcome the challenges posed by mental health issues, substance abuse, trauma, severe family dysfunction, sexual and domestic violence, and human trafficking. Working in close partnership with Human Resources, clinical leadership, billing, and external agencies, the Credentialing Specialist supports timely onboarding, provider readiness, and uninterrupted delivery of safe, high-quality care. This position plays a critical role in maintaining regulatory compliance and operational integrity across the organization. This position is based out of the Gilroy, CA office. Ideal Candidate Will Possess the Following Qualifications and Knowledge Did you know that research shows that women and people from underrepresented groups often apply to jobs only if they meet 100% of the qualifications? Please understand that no one ever meets 100% of the capabilities. If much of this describes you, we encourage you to apply. This might be the right next role for you if you have: Education and Experience Required: Associate degree or equivalent experience and a minimum of two (2) years of administrative experience, preferable in healthcare credentialing, provider enrollment, compliance, or a related field. Preferred: Bachelor's degree in healthcare administration, business administration, or related field. Knowledge Knowledge of Medi-Cal, Medicare, provider enrollment, and healthcare credentialing processes. Working knowledge of NPPES, PAVE, CAQH ProView, and exclusion list monitoring. Special Requirements Must be able to receive a criminal records clearance as required by specific programs, licensing regulations and Community Solutions practices. Position requires an automobile to perform routine job duties. License Must possess a valid California driver’s license, current care insurance and a good driving record as documented by a DMV report and consistent with the Agency’s liability insurance requirements. What You'll Be Doing in the role of – Credentialing Specialist The following are examples of essential job duties for this position. The omission of specific statements of the duties does not exclude them from the classification if the work is similar, related, or a logical assignment for this classification. Other duties may be required and assigned to support the program and Agency. Manage the full credentialing and re-credentialing lifecycle for human service providers and designated clinical staff, ensuring timely completion and ongoing compliance. Conduct primary source verification of licenses, certifications, education, training, work history, and other required credentialing documentation. Process and maintain provider enrollment, revalidation, and credentialing applications with Medi-Cal, Medicare, county systems, commercial payers, and other regulatory entities. Monitor licensure, certification, enrollment, and credential expiration dates; maintain tracking systems and ensure timely renewals to prevent lapses in compliance. Maintain accurate, complete, and up-to-date credentialing records, databases, electronic files, and provider information systems in accordance with agency policies and regulatory standards. Coordinate with Human Resources, clinical leadership, billing, systems/IT, and program staff to support onboarding, transfers, role changes, and ongoing credentialing compliance. Assist providers and staff with obtaining and maintaining credentialing identifiers, including NPI numbers, taxonomy assignments, and related enrollment requirements. Respond to credentialing-related inquiries from staff, providers, payers, auditors, and regulatory agencies in a timely, professional, and customer-service-oriented manner. Prepare and distribute credentialing reports, compliance updates, audit documentation, and status summaries for leadership and internal stakeholders. Conduct routine audits of credentialing records and support internal and external compliance reviews by preparing and submitting required documentation. Identify, investigate, and resolve discrepancies, missing documentation, enrollment delays, and other credentialing issues; elevate complex matters as appropriate. Monitor changes to credentialing, licensing, and payer requirements and recommend updates to workflows, procedures, and documentation practices to maintain compliance. Utilize credentialing software, payer portals, CAQH ProView, Microsoft Office applications, and related systems to maintain accurate documentation and reporting. Demonstrate strong organizational skills, attention to detail, independent judgment, and the ability to manage multiple deadlines in a fast-paced environment. Promote a collaborative, culturally responsive, and solution-focused work environment through effective communication and professional partnership with internal and external stakeholders. Provide backup and ongoing support to the Quality Assurance Administrator staff and assist with special projects and other duties as assigned. Diversity, Equity, and Inclusion Community Solutions is deeply committed to diversity, equity, and inclusion. We are a team of dedicated professionals with backgrounds as diverse as the impact we achieve. We are committed to diversity in our workforce and equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender identity, or Veteran status. We encourage candidates from all backgrounds to apply. Working at Community Solutions Community Solutions offers a competitive and comprehensive pay rate of $28 - $35 per hour, a generous employee benefits package, and encourages a strong work-life balance. We believe in supporting the whole person by providing: 100% of premiums paid by employer for full-time employees and eligible dependent children 403(b) Retirement Plan with 5% employer match 3-weeks paid vacation to start 13 paid holidays; 96 sick hours per year (inclusive of self-care/mental health days) Longevity bonuses Generous family medical leave for eligible employees Student Loan Forgiveness Program Staff learning and development and robust in-house training opportunities Employee-led Diversity, Equity, and Inclusion Resource Group Physical Requirements Different positions may require specific physical capacities that must be met by an employee to successfully perform the essential functions of this position. Sit for extended periods; frequently stand and walk; normal manual dexterity and eye-hand coordination; lift and move objects weighing up to 25 lbs.; corrected hearing and vision to normal range; verbal communication; use of office equipment, including computer, telephone, calculator, copiers, and FAX. Work Environment and Location This position is located within commutable distance to our Gilroy headquarters or San Jose office and is open to a hybrid work schedule, with occasional needs to be able to travel into our offices and work in the evenings or weekends. COVID-19 Vaccination Community Solutions has adopted a COVID-19 vaccination policy to safeguard the health and well-being of our employees and clients. As a condition of employment, employees are required to be fully vaccinated for COVID-19, unless a reasonable accommodation is approved or as otherwise required by law. Additional Information Note: This job description outlines primary duties, qualifications, and job scope, but is not intended to be a comprehensive description of job responsibilities. We expect each employee to offer their services wherever and whenever necessary to ensure the success of our endeavors. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Candidates for this position must be legally authorized to work directly as an employee for any employer in the United States without visa sponsorship. #J-18808-Ljbffr Community Solutions