Credentialing Quality Analyst

Job Summary

The Credentialing Quality Analyst ensures the accuracy, compliance, and timeliness of credentialing and recredentialing processes. This role involves reviewing, auditing, and monitoring credentialing files and workflows to ensure adherence to industry standards, regulatory requirements, and organizational policies. The analyst collaborates with internal teams and external partners to maintain high-quality data and effective credentialing practices.

Key Responsibilities

1. Quality Assurance

   • Audit credentialing and recredentialing files to ensure compliance with regulatory standards  and organizational policies.
   • Identify and correct errors or inconsistencies in credentialing documentation.
   • Provide feedback and recommendations to improve processes and reduce errors.

2. Compliance Monitoring

   • Ensure adherence to state, federal, and accreditation requirements.
   • Stay up-to-date on changes in credentialing regulations and standards.
   • Assist in preparing for internal and external audits.

3. Data Management

   • Validate provider information and maintain accurate data in credentialing systems.
   • Analyze data trends to identify gaps or risks in credentialing processes.
   • Generate reports and dashboards to track quality metrics and performance.

4. Collaboration and Training

   • Collaborate with credentialing specialists, managers, and other stakeholders to ensure seamless workflows.
   • Conduct training sessions or provide coaching on quality standards and compliance best practices.
   • Act as a subject matter expert (SME) on quality-related matters in credentialing.

5. Process Improvement

   • Evaluate existing workflows and recommend improvements to enhance efficiency and quality.
   • Participate in the development and implementation of new credentialing tools or technologies.
   • Document standard operating procedures (SOPs) and quality checklists.

Qualifications

Education & Experience

• Bachelor’s degree in healthcare, business administration, or a related field (preferred).
• 3+ years of experience in credentialing or healthcare quality assurance.

Skills & Competencies

• Strong knowledge of credentialing standards (e.g., CMS).
• Proficiency in credentialing software and data management tools (e.g., CAQH, Verity).
• Exceptional attention to detail and analytical skills.
• Strong organizational and time management abilities.
• Effective written and verbal communication skills.
• Ability to handle confidential information with integrity and discretion.

Certifications (Preferred)

• Certified Provider Credentialing Specialist (CPCS) or similar