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At Lumeris, we believe that our greatest achievements are made possible by the talent and commitment of our team members. That's why we are actively seeking talented and collaborative individuals who are passionate about making a difference in the healthcare industry. Join us today as we strive to create a system of care that every doctor wants for their own family and become part of a community that values its people and empowers you to make an impact.
Position:
Credentialing SpecialistPosition Summary:
The Credentialing Specialist is responsible for coordinating and executing credentialing and re credentialing activities for contracted providers and Health Delivery Organizations (HDOs) in accordance with health plan requirements, state and federal regulations, and NCQA standards. This role ensures the accuracy, integrity, and completeness of credentialing data, supports Credentialing Committee review, and serves as a key liaison with providers, internal partners, vendors, and clients.Job Description:
Key Responsibilities
Credentialing Operations
- Monitor ongoing provider compliance, professional license sanctions, and quality indicators.
- Maintain accurate, complete, and timely credentialing records within credentialing software systems.
Data Integrity & Verification
- Prepare, validate, and submit credentialing data files to the Credentialing Verification Organization (CVO).
- Review, validate, and document the accuracy of CVO‑completed work.
- Identify discrepancies, outstanding issues, or risks within credentialing files and work collaboratively to resolve them.
- Validate credentialing data used for Credentialing Committee materials and reporting.
Collaboration & Communication
- Communicate effectively with providers, physicians, vendors, and internal stakeholders to obtain required documentation.
- Partner cross‑functionally with contracting, client services, and internal departments to exchange provider information and drive efficiency.
- Assist clients, internal partners, and vendors with credentialing‑related questions, outreach, and documentation needs.
- Provide regular (weekly) status updates to assigned clients.
Reporting & Compliance
- Prepare Credentialing Committee materials, including documentation of issues and resolutions.
- Assist with monthly file sampling, audits, SDMC/QMC reporting, and re‑credentialing reports.
- Prepare denial and “criteria not met” notification letters to providers, as applicable.
- Maintain a strong working knowledge of federal, state, and local credentialing regulations across supported markets.
Quality & Confidentiality
- Ensure strict confidentiality of privileged and sensitive information.
- Demonstrate exceptional attention to detail and accuracy across all credentialing activities.
- Support delegated credentialing assessments and ongoing monitoring activities.
- Perform additional duties as assigned to support credentialing and organizational goals.
Qualifications
Required
- High school diploma, GED, or equivalent
- 1+ year of experience in healthcare operations, credentialing, or a related field (or equivalent knowledge, skills, and abilities)
- Familiarity with health plan or credentialing systems
- Proficiency in Microsoft Office and Adobe Acrobat
- Strong verbal and written communication skills
- Exceptional attention to detail and commitment to accuracy
- Strong organizational, multitasking, and time‑management skills
- Ability to prioritize workload and meet deadlines in a fast‑paced, collaborative environment
Preferred
- Associate or Bachelor’s degree in healthcare administration, public health, or a related field
- Credentialing or licensure experience
- Working knowledge of industry standards and regulations (e.g., NCQA, state and federal requirements)
Pay Transparency:
Factors that may be used to determine your actual pay rate include your specific skills, experience, qualifications, location, and comparison to other employees already in this role. In addition to the base salary, certain roles may qualify for a performance-based incentive and/or equity, with eligibility depending on the position. These rewards are based on a combination of company performance and individual achievements.
The hiring range for this position is:
$39,000.00-$48,150.00Benefits of working at Lumeris
Medical, Vision and Dental Plans
Tax-Advantage Savings Accounts (FSA & HSA)
Life Insurance and Disability Insurance
Paid Time Off (PTO, Sick Time, Paid Leave, Volunteer & Wellness Days)
Employee Assistance Program
401k with company match
Employee Resource Groups
Employee Discount Program
Learning and Development Opportunities
And much more...
Be part of a team that is changing healthcare!
Member Facing Position:
No- Not Member or Patient Facing PositionLocation:
Remote, USATime Type:
Full timeLumeris and its partners are committed to protecting our high-risk members & prospects when conducting business in-person. All personnel who interact with at-risk members or prospects are required to have completed, at a minimum, the initial series of an approved COVID-19 vaccine. If this role has been identified as member-facing, proof of vaccination will be required as a condition of employment.
Disclaimer:
The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individual with disabilities to perform the essential job duties and responsibilities.
AU, CA + 4 more