Sr. Credentialing Specialist

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Position Introduction and Overview:
The Sr. Credentialing Specialist is responsible for ensuring that Signify Health's network providers strictly adhere to all necessary business, state, and accrediting body regulatory requirements. This position requires a multi-faceted approach, involving the thorough review, validation, and in-depth investigative analysis of sensitive provider information to directly contribute to data integrity and compliance.

Beyond core credentialing, the Specialist drives process improvement initiatives, manages inquiries from providers and committee members, executes essential administrative and operational support tasks for the Credentialing function and Committee Liaison, and conducts continuous audits and training sessions to enforce standards and educate stakeholders. The primary goals are to ensure strong compliance and effective data management. This, in turn, facilitates close team collaboration to quickly resolve any problems and proactively avoid service disruptions.

Roles & Responsibilities: 

• Compliance and Validation: Thoroughly review and validate all provider information to ensure strict adherence to internal company policies, state regulations, and accrediting body standards.

• Investigative Review and Analysis: Conduct in-depth research and complex analysis on sensitive provider issues. Proactively address any data integrity concerns by preparing and thoroughly reviewing completed investigative files, including complex, risk-sensitive credentialing verifications.

• Process Improvement: Proactively identify, propose, and implement enhancements and solutions to continuously develop and improve credentialing processes and workflows.

• Inquiry Management and Support: Act as the initial contact for providers and committee members, expertly handling their inquiries and resolving issues related to both credentialing and data management.

Administrative and Operational Support:

• Execute both routine and non-routine business support tasks for the Credentialing function under limited supervision, adhering to established procedures and protocols and escalating deviations to management.

• Provide essential administrative support to the Credentialing Committee Liaison, including managing application assignments, distributing official outcome letters, and publishing appointments.

• Maintain organized data collections, tracking, and reporting systems

Auditing and Training:

• Conduct and organize continuous audits to rigorously assess adherence to standards, expected outcomes, and deliverable schedules.

• Create and present impactful education and training on credentialing policies and procedures to both internal teams and healthcare providers.

• Team Collaboration: Cultivate and maintain strong, effective working relationships with team members to collaboratively discuss credentialing requirements, swiftly resolve issues, and prevent service delays.

Basic Qualifications: 

• 2+ years of experience in healthcare operations, or credentialing - preferably with knowledge of processing credentialing applications

• Experience with Credentialing Database Systems preferably MD Staff

• Strong organizational skills with keen attention to detail

• Proficiency in systems such as MD-Staff, Google Suite, PowerBi, and Microsoft Office Suite

• Excellent verbal and written communication skills

• Ability to manage multiple deadlines and work independently in a fast-paced environment

Preferred Qualifications: 

• Ability to adapt to constant change in rules and regulations with minimal supervision

• Meticulous/Conscientious when it comes to state/company compliance

• Proficient in processing all levels of credentialing appl