Remote Credentialing Audit / Quality Control Specialist

Credentialing Auditor

Responsibilities: Perform detailed quality audits on credentialing files to ensure compliance with NCQA, TJC, and organizational standards. Review 3040 provider files per day, verifying accuracy, completeness, and timeliness of all credentialing data. Ensure credentialing files meet internal SLAs and quality benchmarks before submission or approval. Conduct primary source verification (PSV) audits including education, board certifications, and state licenses. Identify data discrepancies or process gaps and provide timely feedback and corrective guidance to credentialing team members. Collaborate closely with offshore credentialing teams to ensure consistent quality and process alignment across time zones. Participate in weekly team syncs (joining a team of two auditors) to review metrics, share feedback, and support ongoing process improvement initiatives. Communicate with internal stakeholders (Credentialing, Enrollment, and Product teams) to resolve issues and enhance workflow efficiency.

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