Senior Credentialing Specialist

Title: Senior Credentialing Specialist

Job Type: Full-time

Location: Hybrid 4 days per week in Brighton MA office; 1 day remote

FLSA Status: Exempt

About Us

BrightonOne is a nonprofit social enterprise delivering healthcare housing and hope to veterans and military-connected families with enterprise discipline in service to those who served.

Position Overview

The Senior Credentialing Specialist leads USFHPs provider credentialing and recredentialing operations ensuring providers meet regulatory and accreditation standards. This role manages the credentialing process end to end application intake primary source verification committee preparation and participation and ongoing monitoring ensuring timely accurate compliant audit-ready credentialing that safeguards network integrity and member safety.

Key Responsibilities

Credentialing & Recredentialing Operations

• Manage initial credentialing and recredentialing end to end including application intake (e.g. CAQH) primary source verification (license education board certification work history malpractice) and file preparation.
• Ensure compliance with NCQA/URAC credentialing standards TRICARE/USFHP DHA and State regulatory requirements and turnaround times.
• Prepare and present clean and adverse files to the credentialing committee; document decisions and maintain accurate records.
• Ensure that approved credentials are quickly provided to the Provider Data Management function.

Ongoing Monitoring & Sanctions

• Perform ongoing monitoring of licensure sanctions and exclusions (e.g. OIG SAM OFAC NPDB state license boards) and escalate findings to the appropriate committee or clinical reviewer(s).
• Track and manage expirables (license DEA malpractice board certification) and provider data updates.

Audit Quality & Delegation

• Maintain audit-ready documentation; support accreditation and regulatory audits and file reviews.
• Support delegated-credentialing oversight and perform required review and audit of Delegates where applicable.

Process Improvement & Collaboration

• Drive credentialing process improvement accuracy and turnaround-time performance.
• Partner with provider data network and compliance teams; guide or mentor credentialing staff as needed.

Qualifications Education & Experience

• Bachelors degree preferred or equivalent experience.
• 4 or more years of provider credentialing experience in managed care or a health plan.
• Experience with NCQA/URAC credentialing standards; CPCS or CPMSM certification preferred.

Skills & Competencies

• Deep knowledge of credentialing standards primary source verification and regulatory requirements.
• Strong attention to detail organization and audit readiness.
• Proficiency with credentialing systems/databases and CAQH; knowledge of NPDB and exclusion sources.
• Familiarity with TRICARE/USFHP preferred.

Other Requirements

• Must be able to obtain and maintain U.S. Government personnel security clearance as a condition of employment.

Physical Nature of the Job

Some elements of the job are sedentary but the employee will be required to stand for periods of time or move throughout the campus.

Equal Opportunity Employer Statement

BrightonOne is an Equal Opportunity Employer. We prohibit discrimination and harassment of any kind based on race color religion sex (including pregnancy gender identity and sexual orientation) national origin age disability genetic information protected veteran status or any other characteristic protected by federal state or local law. We strongly encourage applications from veterans and individuals with disabilities. Accommodations are available upon request for candidates taking part in all aspects of the selection process.

Work Authorization

Candidates must be authorized to work in the United States without sponsorship now or in the future.