NCQA Compliance & Credentialing Specialist (Payer & SaaS)

Obizworks (OBC) is a specialized HR recruitment firm providing top-tier virtual staffing solutions from Pakistan to clients across the US, UK, and Europe. The company is dedicated to improving operational efficiency and reducing costs by connecting businesses with skilled, flexible professionals who integrate seamlessly into existing teams. Leveraging a strong talent pool and structured processes, Obizworks supports organizations in scaling effectively and sustainably.

We are currently seeking a Senior NCQA Credentialing & Accreditation Specialist with direct payer-side experience in health plans, managed care organizations, or delegated credentialing entities. This full-time remote role requires working US business hours and offers a competitive market salary along with additional benefits. The successful candidate will be responsible for evaluating and authenticating extensive provider data, leading delegation audits, conducting NCQA compliance reviews, and ensuring regulatory adherence across complex healthcare networks. Acting as a compliance subject matter expert, the specialist will bridge payer-side data integrity with healthcare SaaS platform requirements.

Key Responsibilities

Payer-Side Delegation Oversight & Data Authentication:
- Audit and validate large datasets of provider credentials, primary source verifications (PSV), and enrollment files across multi-state health plan networks.
- Lead and conduct formal delegation audits on contracted medical groups, Credentialing Verification Organizations (CVOs), and health system partners to assess adherence to NCQA standards.
- Review, score, and certify provider files—including initial credentialing, re-credentialing, and expirable updates—using NCQA-compliant sampling methodologies.

NCQA Accreditation & Audit Readiness:
- Perform comprehensive gap analyses, mock surveys, and pre-audit file reviews to ensure full audit readiness for NCQA accreditation and health plan evaluations.
- Issue, monitor, and re-test Corrective Action Plans (CAPs) for health plan delegates, medical groups, or internal workflows demonstrating compliance deficiencies.
- Draft, maintain, and enforce Credentialing Policies and Procedures aligned with NCQA health plan standards, CMS guidelines, and applicable state regulations.

Healthcare SaaS Logic & Product Collaboration:
- Translate complex NCQA payer standards—such as PSV look-back windows, verification limits, and expirable alert triggers—into automated SaaS software logic.
- Collaborate cross-functionally with Product and Software Engineering teams to design automated compliance reporting, timestamped audit logs, and provider data validation workflows.

Required Qualifications

- 3 to 4+ years of direct experience on the payer side, including health plans, managed care organizations, or delegated credentialing entities (not provider billing or revenue cycle management offices).
- Hands-on experience participating in or leading NCQA Accreditation Surveys, health plan delegation audits, or regulatory compliance reviews.
- Proven ability to review, authenticate, and manage large-scale provider data sets and master provider indexes.
- Demonstrated expertise in conducting gap analyses, drafting formal compliance policies and procedures, and managing end-to-end Corrective Action Plans.
- Bachelor’s degree in Healthcare Administration, Health Information Management, Computer Science, or a related field.
- Full availability to work remotely during US business hours.
- Exceptional written and verbal English communication skills for presenting audit findings and liaising with US-based compliance leads and executive teams.

Preferred Qualifications and Benefits

- NAMSS Certification (CPCS® or CPMSM®) is strongly preferred.
- Competitive salary package with additional benefits.
- Opportunity to work remotely with a reputable international recruitment firm focused on healthcare compliance and technology.

Only candidates with relevant experience will be considered. Applications with AI-generated resumes will not be accepted.