UST
Website:
ust.com
Job details:
Role Description
Job Title: Provider Credentialing Quality Analyst (QC)
Shift: US Shift (5:30 PM - 2:30 AM IST)
Experience: 4-8 Years in US Healthcare Credentialing (Minimum 2+ Years in QC/Audit Role)
Role Summary : We are looking for a highly detail-oriented Provider Credentialing QC Analyst responsible for auditing credentialing processes, ensuring compliance, and maintaining high-quality standards. This role demands excellent communication skills (both oral and written) to interact with internal stakeholders and support client-facing quality expectations.
Key Responsibilities
- Perform end-to-end quality audits of provider credentialing and re-credentialing files
- Validate provider data including:
- Licensure, DEA, CDS
- Board certifications
- Education & training
- Work history and gaps
- Sanctions (OIG, SAM, State exclusions)
- Ensure compliance with:
- NCQA, URAC, and client-specific guidelines
- Identify errors, defects, and process gaps; provide actionable feedback
- Conduct root cause analysis (RCA) for quality issues and recommend corrective actions
- Maintain audit logs, scorecards, and quality reports (daily/weekly/monthly)
- Collaborate with operations/training teams to improve process accuracy
- Support internal/external audits and client reviews
- Drive continuous improvement initiatives and quality enhancement plans
Quality Metrics Ownership
- Audit accuracy 98%
- Defect leakage control
- SLA adherence for QC turnaround time
- Reduction in rework and client escalations
Required Skills & Competencies
- Strong knowledge of Provider Credentialing lifecycle (Enrollment, Revalidation, Maintenance)
- Hands-on experience with:
- CAQH, NPPES, PECOS portals
- Deep understanding of:
- US healthcare compliance and regulatory standards
- Excellent analytical and attention-to-detail skills
- Strong documentation and reporting ability
- Proficiency in MS Excel (pivot, reports, trackers)
- Effective communication and stakeholder management
Mandatory Skills (Critical Requirement)
- Excellent Oral Communication Skills
- Ability to clearly articulate quality feedback, audit observations, and process gaps
- Confident in client/stakeholder discussions and review calls
- Strong Written Communication Skills
- Ability to draft professional audit reports, emails, and documentation
- Clear, concise, and error-free communication is mandatory
Preferred Qualifications
- Experience in payer-side credentialing QC
- Exposure to delegated credentialing audits
- Knowledge of health plan requirements
- Six Sigma / Lean certification (good to have)
- Graduate (Mandatory)
Behavioral Expectations
- High ownership and accountability
- Quality-first mindset
- Ability to work in fast-paced, deadline-driven environment
- Strong problem-solving approach
KPIs / Performance Indicators
- First-pass yield (FPY)
- Audit accuracy score
- Turnaround time (TAT)
- Client satisfaction / audit scores
- Process improvement contributions
As Part Of UST, Candidates Are Expected To Demonstrate
- Humility: Respectful collaboration and openness to feedback
- Humanity: Empathy towards members, providers, and colleagues
- Integrity: Ethical processing and strict adherence to compliance
- Customer Focus: Delivering high-quality outcomes aligned with client expectations
- Excellence: Continuous improvement and ownership of results
Skills
healthcare compliance,provider credentialing,us healthcare compliance,nppes,quality audits,caqh,pecos,
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