Credentialing Auditor

General Summary

Performs routine and targeted audits of credentialing and enrollment work products. Validates documentation and data integrity, identifies compliance gaps, and supports corrective actions to strengthen quality, standardization, and audit readiness.

Duties and Responsibilities

Essential Functions:

• Conducts routine and targeted audits of credentialing and enrollment files to verify completeness, documentation, and adherence to established standards.
• Validates primary source verification evidence, required queries, decision documentation, and file timeliness against policy and checklist requirements.
• Audits delegated credentialing-related work products (e.g., roster files and supporting documentation) to ensure accuracy and completeness prior to submission.
• Reconciles provider data across systems (e.g., Cactus, and internal trackers) and identifies discrepancies requiring correction.
• Documents audit findings, assigns issue categories, and communicates results to operational teams and leadership.
• Tracks corrective actions, verifies completion, and performs re-audits as needed to confirm sustained compliance.
• Maintains audit tools (checklists, sampling logs, scorecards) and produces periodic audit reports and trend summaries.
• Partners with credentialing and enrollment staff to provide feedback and support training opportunities based on audit outcomes.
• Supports internal and external audits by compiling documentation and responding to information requests.

Common Expectations:

• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Maintains professional growth and development.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

• High School Diploma or GED Required
• Associates Degree or higher in a related field Preferred

Work Experience:

• 3 years Experience in provider credentialing, medical staff services, provider enrollment, or related healthcare administrative operations Required
• Quality assurance or audit experience in credentialing/enrollment environments Preferred

Licenses:

• Certified Provider Credentialing Specialist Upon Hire Preferred or
• Certified Professional Medical Services Management Upon Hire Preferred

Knowledge, Skills, and Abilities:

• Strong attention to detail and ability to manage multiple priorities while meeting deadlines
• Proficiency with Microsoft Office (Outlook, Excel, Word) and ability to learn credentialing/enrollment systems
• Effective written and verbal communication skills with providers, payers, and internal stakeholders
• Ability to interpret policies, procedures, and payer/agency requirements and apply them consistently
• Demonstrated discretion and ability to maintain confidentiality of sensitive information
• Ability to apply audit methodology, document findings clearly, and communicate issues with diplomacy and precision

Benefits Offered:

• Comprehensive health benefits
• Retirement savings plan
• Paid time off (PTO)
• Education assistance
• Financial education and support, including DailyPay
• Expanded Paid Parental Leave

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)