Credentialing Specialist

Credentialing Specialist

Position Summary

We are looking for a detail-oriented Credentialing Specialist to own the end-to-end execution of our provider credentialing lifecycle. Reporting to the Credentialing Manager, you will be the engine behind our provider network’s compliance, ensuring that every clinician on our platform meets NCQA, state, and federal standards. You will manage the relationship with our Credentials Verification Organization (CVO), resolve complex enrollment bottlenecks, and ensure our data integrity remains high to prevent RCM claim denials.

What You'll Do

1. End-to-End Credentialing Execution

• Pipeline Management: Manage the full credentialing and re-credentialing cycle for providers across delegated and non-delegated payer arrangements.
• Primary Source Verification: Ensure all provider files (Licensure, DEA, Board Certs, Malpractice) are verified and maintained in accordance with NCQA standards.
• CAQH & System Maintenance: Serve as the internal expert on CAQH ProView; ensure provider profiles are accurate, attested, and synchronized with internal databases.
• CVO Partnership: Act as the primary day-to-day contact for our CVO partners, monitoring their SLAs and auditing their work for accuracy before committee review.

2. Monitoring & Compliance Maintenance

• Expirables Management: Proactively track and manage upcoming expirations for licenses and certifications to prevent provider "dark time" or insurance department.
• Ongoing Monitoring: Execute monthly checks against OIG, SAM, and Medi-Cal/Medicaid sanction lists; investigate and document any "flags" for Manager review.
• Committee Support: Prepare high-quality credentialing packets and summary reports for the Credentialing Committee to ensure efficient decision-making..

3. RCM Collaboration & Process Improvement

• Denial Resolution: Partner with the Revenue Cycle Management (RCM) team to troubleshoot claim denials linked to credentialing or enrollment errors.
• Workflow Optimization: Identify repetitive manual tasks within the credentialing funnel and suggest automation or process shifts to increase "speed to lead" for new providers.

Who You Are

• The "Execution Expert": You have a "no stone left unturned" approach to data. You enjoy the puzzle of matching payer requirements with provider documentation.
• Communication Focused: You can translate complex "credentialing-speak" into simple instructions for providers and internal stakeholders.
• Tech Savvy: You are comfortable navigating Credentialing Software, Zendesk, or Salesforce and can quickly learn new internal tools.
• Autonomous: As a Level 3, you don't need a playbook for every scenario; you can research state-specific regulations and propose a path forward.

Qualifications

• Experience: 4+ years of hands-on healthcare credentialing experience, including directly managing processes end-to-end (Behavioral Health experience is a major plus).
• Regulatory Knowledge: Solid understanding of NCQA standards and the primary source verification process.
• Systems: Proficiency with CAQH and experience working with a CVO.
• Education: Bachelor’s degree preferred, or equivalent years of specialized experience.
• Certification (Preferred): CPCS (Certified Provider Credentialing Specialist).

Benefits:

• We’re a remote-first company
• Health insurance plans through Aetna (medical and dental) and MetLife (vision), including FSA and HSA plans
• 401K plan (ADP)
• Lifestyle Spending Account for health, wellness, and family care
• Monthly co-working space membership stipend
• Monthly work-from-home stipend
• Financial wellness benefits through Northstar
• Pet discount program through United Pet Care
• Financial perks and rewards through PerkSpot
• EAP access through Aetna
• One-time home office stipend to set up your home office
• Inclusive family and medical leave plans
• 12 paid holidays and 1 Alma Give Back Day
• Flexible PTO

Salary Band: $70,000 - $90,000

All Alma jobs are listed on our careers page. We do not use outside applications or automated text messaging in our recruiting process. We will not ask for any sensitive financial or identification information throughout the recruiting process. Any communication during the recruitment process, including interview requests or job offers, will come directly from a recruiting team member with a helloalma.com email address.