Job Description

Job Purpose
The Credentialing & Compliance Auditor is responsible for ensuring the accuracy, completeness, and regulatory compliance of credentialing and enrollment processes. The Credentialing & Compliance Auditor conducts audits, validates documentation, and identifies compliance risks while supporting corrective actions and audit readiness. The Credentialing & Compliance Auditor collaborates with operational teams, delegated contracted insurance partners, and external stakeholders to enhance quality standards, uphold policy adherence, and ensure all activities align with regulatory and organizational requirements.
Duties & Responsibilities
• Performs routine and targeted audits of credentialing and enrollment work products
• Supports external audits by compiling documentation and responding to information requests
• Validates documentation and data integrity, identifies compliance gaps, and supports corrective actions to strengthen quality, standardization, and audit readiness
• Audits delegated credentialing-related work products (e.g., roster files and supporting documentation) to ensure accuracy and completeness prior to submission
• The position is responsible compiling and reviewing policies and procedures. Ensuring an up-to-date copy is on file
• Tracks corrective actions from payers, 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
• Documents audit findings, assigns issue categories, and communicates results to operational teams and leadership
• Partners with credentialing and enrollment staff to provide feedback.
• Use, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards
• Always Understand and comply with Information Security and HIPAA policies and procedures
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties.
Qualifications
• 2nd year undergraduate or bachelors degree
• At least 3 years’ experience in the health care field including, but not limited to, provider’s office, managed care organization, or other health care or regulatory environment, or equivalent combination of relevant education and experience.
• 3+ years healthcare credentialing experience
• Ability to interpret policies, procedures, and payer/agency requirements and apply them consistently
• Ability to learn credentialing/enrollment systems
• 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
• Proficiency in Microsoft Office Suite
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Excellent written and verbal communication skills required

Working Conditions
• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.
Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.