Quality Assurance Specialist – Credentialing

●      Conduct comprehensive credentialing file audits and ongoing quality reviews to ensure compliance with TJC and NCQA standards.

●      Oversee delegated credentialing arrangements, including CVO performance, ensuring adherence to contractual, regulatory, and accreditation requirements.

●      Plan, coordinate, and execute payer credentialing audits, including managing audit documentation, responding to findings, and ensuring timely completion of corrective action plans.

●      Track, trend, and report credentialing quality metrics to internal committees, identifying risks, gaps, and opportunities for improvement.

●      Review, maintain, and update credentialing policies and standard operating procedures to ensure ongoing alignment with TJC, NCQA, and regulatory requirements.

●      Partner with credentialing and provider operations teams to remediate audit findings and implement sustainable process improvements.

●      Support accreditation readiness efforts by participating in TJC and NCQA surveys, including mock surveys and live accreditation reviews.

●      Assist in the collection, validation, and submission of required documentation and data for accreditation surveys and regulatory reviews.

●      Monitor credentialing processes to ensure ongoing compliance with internal policies and external regulatory standards.

●      Identify compliance risks, escalate issues appropriately, and recommend corrective and preventive actions.

●      Maintain audit-ready documentation and ensure alignment across credentialing systems, policies, and procedures.

●      Collaborate cross-functionally with Provider Success, Compliance, Legal, and Operations teams to ensure a consistent and compliant credentialing program.

●      Bachelor’s degree preferred (or equivalent work experience).

●      3+ years of credentialing, quality assurance, compliance, or healthcare operations experience, preferably in a behavioral health, hospital, or managed care setting.

●      Strong knowledge of The Joint Commission and NCQA credentialing and accreditation standards required.

●      Experience conducting credentialing audits, payer audits, and/or delegation oversight (including CVOs).

●      Demonstrated experience managing corrective action plans and driving compliance improvements.

●      Familiarity with accreditation survey processes, including documentation preparation and survey participation.

●      Strong analytical skills with the ability to track, interpret, and report quality metrics.

●      Exceptional attention to detail with a focus on accuracy, compliance, and audit readiness.

●      Excellent communication skills, with the ability to clearly present findings, risks, and recommendations to stakeholders.

●      Experience with credentialing systems, audit tools, and platforms such as Salesforce, Jira, or similar systems preferred.

●      Strong organizational and project management skills, with the ability to manage multiple audits and deadlines simultaneously.

●      Proactive, solutions-oriented mindset with the ability to identify gaps and drive continuous improvement.

●      Passion for advancing high-quality, compliant mental health care and supporting provider excellence.