Credentialing and Provider Enrollment Specialist

Position Title:  Credentialing Team Lead
Department:  Credentialing Operations
Reports To:  Director of Credentialing / VP of Operations
Location:  Hybrid— Philippines
Employment Type:  Full-time
 
Position Summary
This role is responsible for directing and managing the end-to-end healthcare provider credentialing process to ensure full regulatory compliance and data integrity. You will oversee primary source verification, maintain meticulous documentation for licenses and certifications, and ensure all provider records adhere to CMS, HIPAA, and payer-specific standards. The ideal candidate will be a detail-oriented professional capable of managing complex databases and supporting internal and external audits to maintain a high standard of organizational oversight.
 
Key Responsibilities 
 

• Provider Credentialing Oversight: Direct and manage the full credentialing process for all new and existing healthcare providers, ensuring accuracy, timeliness, and compliance.
• Documentation Management: Obtain, verify, and maintain all required documents, including licenses, certifications, educational records, malpractice coverage, and other credentialing materials.
• Regulatory Compliance: Ensure full adherence to state, federal, and industry regulations, including CMS, HIPAA, and payer-specific credentialing requirements.
• Data Management and Record Keeping: Accurately maintain up-to-date provider information in credentialing systems or databases, ensuring data integrity and accessibility.
• Credential Verification: Conduct primary source verifications with licensing boards, educational institutions, training programs, and medical facilities to validate provider qualifications.
• Database Maintenance: Organize and maintain credentialing records and electronic files for easy access by authorized staff, supporting internal audits and external inspections.

Required Qualifications

• Requires 2+ years of leadership experience within healthcare credentialing or CVO (Credentialing Verification Organization) operations
• Direct experience with NCQA credentialing standards (CVO or CR) — Preferred
• Experience preparing for and/or participating in NCQA surveys or health plan audits - Preferred
• Strong policy and procedure writing skills
• Proficiency with credentialing software (CAQH, VerityStream, Cactus, or similar)
• Excellent English written and verbal communication

Preferred Qualifications

• CPCS (Certified Provider Credentialing Specialist) or CPMSM certification from NAMSS
• Experience with delegated credentialing arrangements
• Prior work at an NCQA-certified CVO
• Familiarity with JCAHO, CMS, and state credentialing requirements