Payer Delegation and Compliance Specialist

A5 Healthcare (Anders Affiliate) one of one of the fastest-growing Credentialing Verification Organizations in the country is seeking a Payer Delegation and Compliance Specialist who is motivated to learn, excited to collaborate and passionate about delivering outstanding results. This individual will have a direct impact on our firm’s mission of serving as a catalyst for those striving to achieve their highest potential. 

The Payer Delegation and Compliance Specialist at A5 Healthcare serves a critical role in ensuring that delegated healthcare tasks and responsibilities are executed in compliance with NCQA regulatory standards and organizational policies for the Primoris Independent Physician Association (IPA). This position is responsible for delegated credentialing, compliance monitoring, performance assessment, file audits and analysis, and improving the delegation processes to enhance client quality and operational efficiency. Communication and accountability in delegated functions are essential to meeting NCQA CR accreditation requirements.

What You’ll Do:  

Payer Delegation

• NCQA standards (understand and identify changes necessary to comply with NCQA standards)
• CAQH Application retrieval and review
• File Audit and Analysis for inappropriate documentation and updates to credentialing information
• Conduct qualitative analysis of inappropriate documentation and updates
• Payer Rosters must be completed in accordance with A5’s policy and procedures.
• Credentialing Information Integrity
• Policy and procedure (writing and updating in accordance with payer and NCQA standards)
• Trouble shoot and problem solve implementation challenges related to NCQA standards, policy, and procedures
• Evolution of system controls requirements

Team Collaboration

• Communicate regularly with the non-delegated provider enrollment and CVO teams.
• Support teamwork balancing by assisting in complex case management and troubleshooting.
• Collaborate cross-functionally with internal stakeholders such as compliance, provider relations, and operations.

General Responsibilities

• Maintain in-depth knowledge of evolving payer policies, credentialing regulations, and accreditation standards.
• Analyze data and produce reports on credentialing metrics and trends.
• Participate in continuous improvement initiatives and credentialing software optimization.
• Promote a collaborative, high-performance culture in a fully remote or hybrid team environment.

What We’re Looking For:   

• Proven leadership ability and experience mentoring or training junior staff.
• Advanced understanding of CVO credentialing workflows, payer delegation requirements, and NCQA regulatory compliance.
• High-level organizational and problem-solving skills with keen attention to detail.
• Excellent written and verbal communication; capable of handling sensitive issues with professionalism.
• Proficient in credentialing and enrollment systems, with strong Excel and Microsoft Office Suite skills.
• Self-directed, accountable, and capable of managing priorities in a fast-paced remote environment.

Your Qualifications:  

• Associate’s degree required; Bachelor’s degree in healthcare administration or a related field preferred.
• Minimum 5 years of experience in delegation and compliance, payer enrollment or healthcare credentialing, including experience with NCQA, URAC, and CMS standards.
• Certification as a NAMSS Certified Provider Enrollment Specialist (CPES) is strongly preferred.

Applicants to the Payer Delegation and Compliance Specialist position must be located within the Greater St. Louis, MO area or Tulsa, OK.