Credentialing Audit & Quality Specialist

Job Description

Job Description

Description

The Quality Assurance Reviewer ensures healthcare providers are appropriately credentialed with health plans and regulatory agencies. This role involves maintaining accurate records, submitting applications, and ensuring compliance with industry regulations. As the primary liaison between healthcare providers and health plans, the coordinator ensures timely and efficient completion of credentialing processes.

What You'll Do

• Review and process healthcare providers’ credentialing applications to ensure compliance with health plan participation requirements.
• Verify providers’ professional qualifications, including education, licensure, and certifications.
• Maintain and update credentialing records for all providers within the health plan network.
• Submit credentialing applications to health plans for review and approval.
• Monitor re-credentialing timelines, ensuring timely renewal of certifications, licenses, and memberships.
• Ensure compliance with federal, state, and health plan-specific regulations and policies.
• Collect required documentation from providers, including diplomas, licenses, certifications, and malpractice insurance.
• Address and resolve discrepancies or issues encountered during the credentialing process.
• Protect the confidentiality of sensitive provider and patient information.
• Assist with audits and respond to health plan inquiries regarding credentialing status.
• Collaborate with internal departments to resolve credentialing-related issues and maintain accurate data

Qualifications

Preferred Qualifications :

Environmental Job Requirements and Working Conditions