Job Description

Delegation Oversight Credentialing Specialist

Hybrid Onsite Schedule | Monday Friday, 8:00 AM 4:15 PM

We are seeking a detail-oriented and compliance-driven Delegation Oversight Credentialing Specialist to join our Delegation Oversight team. In this role, you will play a critical part in ensuring our delegated credentialing vendors maintain full compliance with NCQA, CMS, and regulatory standards. Youll lead and perform credentialing audits, review policies and procedures, and partner closely with vendors to drive continuous improvement and operational excellence.

Key Responsibilities

• Lead, coordinate, and participate in delegation oversight activities for credentialing vendors to ensure adherence to state, federal, and accreditation standards.
• Conduct pre-delegation assessments for onboarding new vendors and ensure readiness to meet contractual and regulatory requirements.
• Review and validate delegate rosters for accuracy and completeness prior to processing.
• Perform annual and ongoing credentialing/recredentialing audits and policy reviews to ensure compliance with NCQA, CMS, and internal guidelines.
• Conduct Medicare Compliance Program Effectiveness audits, identifying gaps and driving corrective actions.
• Track and analyze audit findings, identify trends, and prepare reports for management and Delegation Oversight Committees.
• Develop, monitor, and report on Corrective Action Plans (CAPs), providing clear feedback and performance updates to delegates.
• Stay current with changes in credentialing and recredentialing requirements and ensure implementation across vendors.
• Present findings, trends, and compliance updates to internal committees and leadership teams.

Qualifications

• 35 years of experience in a regulatory, accreditation, credentialing, or compliance role within the health insurance, healthcare, or managed care industry.
• Associates degree in Business, Healthcare, or a related field (or equivalent combination of education and experience).
• Proven auditing experience within credentialing operations or CMS/NCQA-regulated environments.
• Strong working knowledge of NCQA standards, CMS regulations, and Medicare compliance programs.
• Exceptional written and verbal communication skills with the ability to present audit results and compliance recommendations effectively.
• Highly organized, with strong attention to detail and the ability to manage multiple priorities.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) and Adobe Acrobat.

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