CREDENTIALING SPECIALIST

Job Details
Job Location
Huntington Beach Office - Huntington Beach, CA
Secondary Job Location(s)
Arcadia Office - Arcadia, CA
Position Type
Full Time
Description
Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.
Who Are We?
Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.
Why Join Us?
We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.
Job Summary
Under the supervision of the Vice President of Operations, the Credentialing Specialist supports all credentialing operations, including direct monitoring of the delegated Credentials Verification Organization (CVO) vendor (Gemini). This role ensures that all aspects of the provider and facility credentialing and re-credentialing lifecycle meet CMS, NCQA, and internal quality standards. In addition, the Credentialing Specialist will conduct Facility Site Reviews (FSRs), manage credentialing committee presentations, maintain policy and procedure documentation, and support quality and compliance initiatives across the provider network.
Functions & Job Responsibilities

• Serve as the primary liaison and monitor for Gemini, the delegated CVO vendor, ensuring performance against contractual standards and audit readiness.
• Review and validate provider and facility applications for completeness and compliance with internal, regulatory, and accreditation standards.
• Perform and document Facility Site Reviews (FSRs), summarize findings, and present to Credentialing Committee with clear recommendations.
• Prepare detailed credentialing summaries and present provider and facility files for review by the Credentialing Committee.
• Draft and update credentialing and recredentialing policies, procedures, workflows, and job aids to align with current standards.
• Monitor expiring documents (licenses, insurance, certifications) and coordinate timely outreach and updates.
• Coordinate and participate in Credentialing Committee meetings: schedule, prepare meeting packets, capture minutes, and issue decision notifications.
• Maintain credentialing and contract-related data in systems (e.g., CAQH, credentialing software), ensuring accuracy, confidentiality, and real-time updates.
• Ensure compliance with CMS, NCQA, DHHS, and other applicable regulations regarding credentialing, delegated oversight, and exclusion/sanction monitoring.
• Investigate red flags such as license sanctions or gaps in work history; escalate to Medical Director and Credentialing Committee as needed.

• Prepare all correspondence related to credentialing status, including approvals, denials, and appeal communications.
• Support provider onboarding processes in coordination with Provider Services and other internal departments.
• Participate in audit preparation and corrective action plans relating to credentialing functions.
• Ensure all providers and facilities in the network meet regulatory and risk management criteria.
• Other duties as assigned.

Qualifications
Qualifications
Education & Experience:

• Undergraduate degree in healthcare, business, or related field required; Bachelor's preferred.
• 3+ years of direct hands-on credentialing experience in a health plan, IPA, or delegated model.
• Experience working with CVOs, delegated entities, or delegated oversight structures required.
• Experience conducting or coordinating Facility Site Reviews preferred.
• CPCS or equivalent credentialing certification preferred.

Skills:

• Knowledge of CMS, NCQA, state regulations, and delegated credentialing standards.
• Familiarity with credentialing software and systems (e.g., CAQH, IntelliCred).
• Proficient in Microsoft Office Suite and credentialing databases.
• Strong written and verbal communication skills, including the ability to present findings to leadership-level committees.
• Highly organized and detail-oriented with the ability to manage multiple competing priorities.
• Strong interpersonal skills and professional demeanor, with the ability to work cross-functionally.
• Meet productivity standards as outlined in department metrics
• Ability to Identify any issues or trends and bring them to the attention of management team with recommendation for resolution.
• Extensive experience using a computerspecifically internet research, Microsoft Outlook, Word, Excel and other software systems.

Wage Range : $24.00/hour - $29.00/hour
Physical & Working Environment.
Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Primarily remote with potential for occasional travel (e.g., FSRs or in-person meetings).
• Ability to operate standard office equipment, including computers, phones, and video conferencing tools.
• Must be able to sit, stand, and move about for prolonged periods; lift up to 15 lbs occasionally.
• Work involves frequent contact with internal departments and external stakeholders.
• Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate's state residency.
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