Role Overview: The Credentialing Auditor is responsible for conducting quality audits of practitioner and organizational provider files to ensure compliance with National Committee for Quality Assurance (NCQA) standards and state and federal regulations. This role performs initial and ongoing audits, monitors the accuracy of Credentialing Coordinators’ work, and provides constructive feedback to support continuous improvement. The Auditor also collaborates with the Enterprise Credentialing Trainer to identify departmental training needs.

Work Arrangement:

• Hybrid - This role requires the associate to be onsite at the Philadelphia, Pennsylvania office at least three days per week, including mandatory in-office days on Tuesdays and Wednesdays.

Responsibilities:

• Audit 100% of credentialing and re-credentialing files submitted by Credentialing Coordinators for accuracy and completeness.
• Review both data entry in the Credentialing S-Provider system and supporting documentation.
• Return audited files to Credentialing Coordinators for correction and educational feedback.
• Generate monthly audit reports highlighting trends, performance gaps, and opportunities for improvement at both individual and departmental levels.
• Communicate clearly and professionally, demonstrating strong decision-making, negotiation, and conflict resolution skills.
• Partner with the Enterprise Credentialing Trainer to address educational needs within the credentialing team.
• Identify and report potential training needs based on audit findings.

Education & Experience:

• High School Diploma or GED with a minimum of 5 years of credentialing experience, or
• Associate’s Degree with a minimum of 3 years of credentialing experience.
• Bachelor’s Degree preferred.
• 3 to 5 years of provider credentialing experience in a managed care or healthcare setting.
• Experience working with credentialing databases; familiarity with Cactus/S-Provider highly preferred.
• Knowledge of healthcare principles, managed care operations, and medical terminology preferred.
• Proficiency in Microsoft Office applications (Excel, Word, Access).

Skills & Abilities:

• Strong verbal and written communication skills.
• Excellent organizational, analytical, and negotiation abilities.
• Ability to manage and resolve problems and conflicts effectively.
• High attention to detail and accuracy.
• Capable of independently planning and prioritizing work to meet deadlines.
• Comfortable working in a metrics-driven environment.