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CenCal Health

Credentialing Specialist

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California Central Coast Hourly Range: $26.30 - $36.82

Job Summary

The Credentialing Specialist is responsible for executing provider credentialing, recredentialing, and related enrollment activities in accordance with NCQA, DHCS, CMS, and CenCal Health standards.

This role ensures the accurate, timely, and consistent collection, verification, and maintenance of provider credentialing data, while supporting audit readiness, regulatory compliance, and operational efficiency.

The Credentialing Specialist operates within a structured, team-based environment that emphasizes standardized workflows, shared documentation, and cross-functional collaboration.

This role executes established processes, maintains data integrity, escalates complex or high-risk issues, and contributes to continuous improvement efforts that support a scalable and compliant credentialing program.

Duties and Responsibilities

1. Credentialing Operations, Data Integrity, and Compliance Execution

  • Process initial credentialing and recredentialing applications in accordance with established workflows, regulatory requirements, and internal service level expectations

  • Perform primary source verification using approved and authoritative sources (e.g., state licensing boards, NPDB, OIG, SAM, CMS databases)

  • Prepare provider files to ensure completeness, accuracy, and audit readiness prior to review by leadership and the credentialing committee

  • Monitor credentialing and recredentialing cycles to ensure timely processing and compliance with regulatory requirements

  • Execute all activities consistently in alignment with established policies, procedures, and standard operating processes

  • Accurately enter and maintain provider information within credentialing systems and databases

  • Maintain complete, organized, and compliant electronic credentialing files to ensure accessibility, continuity, and audit readiness across team members

  • Perform data validation and quality checks to ensure accuracy and consistency across systems

  • Identify and resolve data discrepancies in coordination with internal teams

2. Provider Communication and Enrollment Support

  • Communicate with providers to obtain required documentation and resolve credentialing deficiencies

  • Provide general guidance and education to providers regarding credentialing and enrollment requirements, including PAVE (Medi-Cal) and PECOS (Medicare), while ensuring providers remain solely responsible for application completion and submission

  • Support providers using a guided, educational approach aligned with organizational standards

  • Maintain professional, timely, and consistent communication to support provider experience and minimize delays

3. Escalation, Risk Identification, and Issue Resolution

  • Identify incomplete, non-compliant, or high-risk applications, including those involving sanctions, adverse information, or discrepancies

  • Escalate complex or non-standard cases to the Provider Qualifications Supervisor for review and determination in accordance with established protocols

  • Identify potential compliance risks or documentation gaps and escalate in a timely manner

4. Committee Support, Audit Readiness, and Performance Tracking

  • Prepare credentialing files, summaries, and supporting documentation for review by the Peer Review and Credentialing Committee (PRCC)

  • Support the coordination of committee meetings, including preparation of materials and documentation

  • Accurately document credentialing outcomes and maintain appropriate records

  • Support internal and external audits, including NCQA surveys, regulatory reviews, and related documentation requests as directed

  • Ensure credentialing files and documentation meet audit and accreditation standards

  • Adhere to established policies, procedures, and documentation requirements to ensure compliance

  • Track and document credentialing activities, application status, deficiencies, and turnaround times to support workload monitoring and performance metrics

  • Support leadership visibility into processing volumes, timelines, and overall workflow status

5. Process Standardization, Knowledge Sharing, and Continuous Improvement

  • Follow standardized workflows, documentation practices, and established procedures to ensure consistency and transparency across the team

  • Contribute to the development, maintenance, and utilization of shared documentation, job aids, and standard operating procedures

  • Participate in cross-training and knowledge-sharing activities to support operational continuity and team flexibility

  • Perform additional duties as assigned to support departmental and organizational objectives