Credentialing Specialist

Community Solutions•Gilroy, CA

9d•Hybrid

About The Position

Community Solutions (CS) is a comprehensive nonprofit human services agency providing prevention, intervention, treatment, and residential services to over 6,400 clients annually. The Credentialing Specialist, working in partnership with Human Resources, clinical leadership, billing, and external agencies, supports timely onboarding, provider readiness, and uninterrupted delivery of safe, high-quality care. This position is critical for maintaining regulatory compliance and operational integrity across the organization and is based out of the Gilroy, CA office.

Requirements

Associate degree or equivalent experience
A minimum of two (2) years of administrative experience, preferable in healthcare credentialing, provider enrollment, compliance, or a related field.
Knowledge of Medi-Cal, Medicare, provider enrollment, and healthcare credentialing processes.
Working knowledge of NPPES, PAVE, CAQH ProView, and exclusion list monitoring.
Must be able to receive a criminal records clearance as required by specific programs, licensing regulations and Community Solutions practices.
Position requires an automobile to perform routine job duties.
Must possess a valid California driver’s license, current care insurance and a good driving record as documented by a DMV report and consistent with the Agency’s liability insurance requirements.
Sit for extended periods; frequently stand and walk; normal manual dexterity and eye-hand coordination; lift and move objects weighing up to 25 lbs.; corrected hearing and vision to normal range; verbal communication; use of office equipment, including computer, telephone, calculator, copiers, and FAX.

Nice To Haves

Bachelor's degree in healthcare administration, business administration, or related field.

Responsibilities

Manage the full credentialing and re-credentialing lifecycle for human service providers and designated clinical staff, ensuring timely completion and ongoing compliance.
Conduct primary source verification of licenses, certifications, education, training, work history, and other required credentialing documentation.
Process and maintain provider enrollment, revalidation, and credentialing applications with Medi-Cal, Medicare, county systems, commercial payers, and other regulatory entities.
Monitor licensure, certification, enrollment, and credential expiration dates; maintain tracking systems and ensure timely renewals to prevent lapses in compliance.
Maintain accurate, complete, and up-to-date credentialing records, databases, electronic files, and provider information systems in accordance with agency policies and regulatory standards.
Coordinate with Human Resources, clinical leadership, billing, systems/IT, and program staff to support onboarding, transfers, role changes, and ongoing credentialing compliance.
Assist providers and staff with obtaining and maintaining credentialing identifiers, including NPI numbers, taxonomy assignments, and related enrollment requirements.
Respond to credentialing-related inquiries from staff, providers, payers, auditors, and regulatory agencies in a timely, professional, and customer-service-oriented manner.
Prepare and distribute credentialing reports, compliance updates, audit documentation, and status summaries for leadership and internal stakeholders.
Conduct routine audits of credentialing records and support internal and external compliance reviews by preparing and submitting required documentation.
Identify, investigate, and resolve discrepancies, missing documentation, enrollment delays, and other credentialing issues; escalate complex matters as appropriate.
Monitor changes to credentialing, licensing, and payer requirements and recommend updates to workflows, procedures, and documentation practices to maintain compliance.
Utilize credentialing software, payer portals, CAQH ProView, Microsoft Office applications, and related systems to maintain accurate documentation and reporting.
Demonstrate strong organizational skills, attention to detail, independent judgment, and the ability to manage multiple deadlines in a fast-paced environment.
Promote a collaborative, culturally responsive, and solution-focused work environment through effective communication and professional partnership with internal and external stakeholders.
Provide backup and ongoing support to the Quality Assurance Administrator staff and assist with special projects and other duties as assigned.

Benefits

100% of premiums paid by employer for full-time employees and eligible dependent children
403(b) Retirement Plan with 5% employer match
3-weeks paid vacation to start
13 paid holidays
96 sick hours per year (inclusive of self-care/mental health days)
Longevity bonuses
Generous family medical leave for eligible employees
Student Loan Forgiveness Program
Staff learning and development and robust in-house training opportunities
Employee-led Diversity, Equity, and Inclusion Resource Group