Credentialing Specialist

• Develop and execute strategies to reduce insurance denials and payer write-offs
• Identify, analyze, and prioritize denial and non-payment root causes across modalities, payers, and sites
• Design and implement systematic solutions to prevent recurring denials
• Identify denial trends and convert them into operational SOPs
• Follow up with payers to resolve claim denials and payment discrepancies
• Investigate payment and reimbursement delays and support accurate claims processing
• Monitor and track outstanding accounts receivable
• Collect, verify, maintain, and update facility and provider credentials
• Prepare and submit initial and re-credentialing applications
• Maintain electronic credentialing files and track credential expirations and renewals
• Submit provider enrollment applications for Medicare, Medicaid, and commercial payors
• Manage enrollments through CAQH, PECOS, NPPES, and payor-specific portals
• Follow up with payors regarding delays, missing documentation, and application deficiencies
• Confirm provider participation status and effective dates
• Maintain up-to-date fee schedules
• Update payors on provider demographics, locations, group affiliations, and tax information
• Maintain compliance documentation for audits and internal reviews
• Partner with billing, revenue cycle, and leadership teams to resolve credentialing- and enrollment-related claim issues
• Communicate with internal teams via email, phone, and virtual meetings
• Manage workload independently while meeting deadlines and productivity expectations

Credentialing/Payor Specialist

• Onboard and maintain credentialing of providers with state boards
• Manage and review credentialing files on credentialing platform for accuracy and completeness
• Perform primary source verifications via various state and national sources
• Obtain new and renewed state licenses for providers
• Participate in the development of internal credentialing processes
• Ensure compliance with applicable laws, licensing requirements, regulations, procedures, and policies
• Report to the Credentialing Manager
• Work closely with the Credentialing Manager and Credentialing Lead
• Support licensing initiatives and maintain accurate, up-to-date provider credentials
• Contribute to departmental goals and initiatives

• Follow and maintain credentialing & clinic licensure policies and protocols
• Ensure reports on the credentialing status of providers are up-to-date and accurate
• Ensure all clinic information is accurate within payor directories
• Process applications, verify information, research application details, and ensure processes are accurate and completed promptly
• Maintain up-to-date data for each provider in the credentialing database and online systems
• Monitor staff credentials and licenses
• Work closely with the Credentialing Manager and billing staff to identify and resolve denials or authorization issues related to provider credentialing
• Complete revalidation requests issued by payers
• Perform other tasks as assigned

• Oversee delegated credentialing activities for an assigned payer portfolio, including readiness reviews, ongoing compliance monitoring, recurring reporting, and annual audits
• Monitor NCQA guidance, state regulations, and accreditation updates; assess operational impact and implement compliance changes
• Prepare for and facilitate pre-delegation and annual credentialing audits; develop and track corrective action plans through resolution
• Maintain complete, audit-ready credentialing records, including primary source verification, Credentialing Committee documentation, and adverse action logs
• Prepare recurring deliverables for delegated partners and payers, such as provider rosters, audit materials, and credentialing activity reports
• Monitor average time to credential, identify delays, manage follow-up, and escalate issues as needed
• Partner with Enrollment, Partnerships, Revenue Cycle, Legal/Compliance, and other teams to maintain accurate provider data and reconcile internal records against delegated payer rosters
• Serve as a point of contact for payer communications related to delegated credentialing activities, audits, provider records, and follow-up items
• Support implementation of new delegated credentialing agreements, including processes and controls for contractual requirements
• Lead Credentialing Committee meetings, including preparation, execution, minutes, training materials, records, and follow-up
• Lead credentialing for Nurse Practitioners, including application review, primary source verification, committee readiness, payer submissions, follow-up, and status tracking
• Support credentialing for group practice providers by coordinating documentation, resolving application gaps, monitoring timelines, and maintaining accurate provider records

• Maintain timely and accurate credentialing and re-credentialing of all Independent Health providers
• Manage provider files and documentation in adherence with regulatory requirements and Independent Health policies
• Work with internal departments to ensure provider data accuracy
• Provide effective, professional external customer service
• Maintain all work through the Healthrules system
• Input provider applications into the credentialing database and process within required time frames
• Ensure applications are complete, accurate, and compliant with NCQA, DOH, CMS, and Independent Health policy requirements
• Complete and close clean, routine applications and assigned recredential files within required time frames
• Initiate credentialing packets as assigned and scheduled
• Track processes to maintain compliance with federal, state, NCQA, and internal requirements
• Follow up and take action on conflicting or incomplete information
• Review and edit files for completeness and accuracy before analyst review
• Maintain Network Evaluation process and physician network profiles
• Gather and document information from respective departments for recredentialing review
• Perform primary source verification using credentialing software according to IPA/WNY policies and procedures
• Query primary sources by letter or phone to verify information
• Initiate additional requests when responses are not received within required time frames
• Query databases and internet sources to verify licenses, board information, sanctions, and claims history
• Maintain the credentialing database and provider hard-copy files
• Enter changes and update provider credentialing database records in Cactus and Health Rules
• Remain current and informed on credentialing policies and procedures
• Generate routine and follow-up reports from the system
• Provide the manager with month-end status reports of assigned files

• Prepare, submit, and manage provider credentialing and payer enrollment applications for commercial, Medicare, Medicaid, and other health plans
• Coordinate initial credentialing, recredentialing, and provider data maintenance for physicians and advanced practice providers
• Maintain accurate provider files, including CAQH profiles, NPI information, state licenses, DEA certificates, malpractice insurance, board certifications, and other required documentation
• Maintain credentialing, enrollment, and contracting records in CredentialStream and other designated databases
• Monitor credentialing and enrollment statuses through payer portals and follow up to ensure timely approvals
• Track expiration dates for licenses, certifications, malpractice coverage, and other required documents
• Respond to payer requests for additional documentation or clarification
• Communicate status updates to leadership, billing managers, clinic managers, providers, and other stakeholders
• Assist with onboarding new providers, including credentialing timelines, payer enrollments, and hospital privileging requirements
• Support provider offboarding, including payer terminations and record updates
• Maintain confidentiality and ensure compliance with HIPAA and organizational policies
• Proactively identify and resolve credentialing or enrollment delays
• Maintain complete, accurate, and organized records and manage multiple provider enrollment timelines and deadlines

Credentialing and Enrollments Specialist

• Coordinate all activities associated with credentialing and re-credentialing of physicians and providers
• Ensure credentialing policies and procedures meet organizational, state regulatory, and external accreditation requirements
• Implement and monitor procedures related to credentialing, re-credentialing, and privileging of network providers
• Process provider applications and re-applications, including initial mailing, review, and database loading
• Lead training initiatives for less experienced specialists
• Participate in proctoring credentialing exams
• Conduct regular file audits
• Maintain the provider profiling system
• Communicate with providers by phone and mail regarding credentialing status
• Provide guidance or expertise to less experienced specialists
• Serve as a liaison during credentialing processes
• Assist in managing credentialing policies, procedures, and provider delegation maintenance
• Ensure compliance with Memorial Hermann policies, procedures, standards, budgetary specifications, time management, supply management, productivity, and quality of service
• Support department-based goals and serve as a preceptor, mentor, and resource to less experienced staff
• Model Memorial Hermann service standards and provide safe, caring, personalized, and efficient experiences
• Perform other duties as assigned

Senior Credentialing Specialist – Hybrid

• Coordinate initial credentialing, recredentialing, and payer enrollment for physicians, advanced practice providers, and other licensed clinicians
• Manage Medicare, Medicaid, and commercial payer enrollment applications across multiple states
• Perform primary source verifications and revalidations
• Submit and manage provider demographic updates, location additions, participation requests, and other enrollment changes
• Monitor applications through completion and follow up with payers to resolve delays or discrepancies
• Maintain provider credentialing files, databases, and reporting systems
• Monitor and update CAQH, PECOS, NPPES, Availity, and state enrollment systems
• Track and manage expirations for licenses, DEA registrations, malpractice insurance, board certifications, attestations, and other credentials
• Maintain compliance with Holon Health policies, NCQA standards, CMS requirements, and state and federal regulations
• Prepare documentation for audits, accreditation reviews, and payer credentialing requests
• Support provider onboarding and new market expansion
• Maintain provider rosters and coordinate submissions to participating health plans
• Respond to credentialing inquiries from providers, health plans, regulatory agencies, and internal stakeholders
• Manage credentialing inboxes and daily workflows, including approvals, denials, appeals, and payer correspondence
• Partner with Operations, Leadership, Contracting, and Compliance teams
• Identify process improvements to increase efficiency, accuracy, and turnaround times

• Work closely with the local market onboarding team on all new providers in the pipeline.
• Request credentialing data and supporting documents from physicians.
• Communicate physician-related delays that may jeopardize project timelines.
• Prepare and/or update provider CAQH applications for newly affiliated and existing healthcare providers.
• Communicate newly affiliated providers to health plans to initiate TIN changes, demographic flips, or credentialing.
• Establish credentialed status to facilitate billing.
• Maintain credentialing databases and up-to-date file process tracking.
• Execute standard operating procedures and communicate issues, trends, and concerns to the Regional Supervisor.
• Identify process improvement opportunities and work with the Regional Supervisor on payor-related challenges.
• Complete workflow items within required turnaround times and quality expectations.
• Resolve billing and collections issues for services rendered.
• Educate internal markets on payor contractual obligations, authorizations, billing requirements, and operational procedures.
• Provide credentialing information to Market Operations.
• Perform data entry, initial credentialing or recredentialing per NCQA, health plan submissions, and UCC credentialing.

Senior Credentialing Specialist, TPR

• Manage full-cycle credentialing and re-credentialing activities for clinical and ancillary providers
• Conduct primary source verification of licensure, education, training, certifications, and employment history
• Collect, review, and maintain credentialing documentation and provider files
• Upload and maintain documentation in the MD-Staff-approved credentialing software system
• Conduct NPDB queries, sanctions checks, background checks, and other required screenings
• Prepare and submit credentialing packets to military treatment facilities and applicable governing or oversight organizations
• Coordinate provider privileging and appointment processes with military treatment facility personnel and other stakeholders
• Track licenses, certifications, and expirable credentials to ensure timely renewals and continued compliance
• Communicate with providers and third-party organizations to obtain missing or incomplete documentation
• Conduct periodic audits of credentialing files for accuracy, completeness, and compliance
• Collect, analyze, and report credentialing data and compliance metrics
• Prepare reports on credentialing status, timelines, and compliance
• Identify process improvement opportunities and make recommendations
• Remain current on credentialing requirements, regulations, standards, and best practices
• Perform other duties as assigned