Sr Credentialing Specialist, Full Time, First Shift

UC Health • Cincinnati, OH

9h

About The Position

This is a multifaceted position encompassing administrative tasks, customer service, and credentialing verifications. The Sr Credentialing Specialist prepares, documents, and completes credentialing data processes, including applications and verifications for Medical and Allied Health staff. The role also compiles provider data, prepares applications, maintains organized files, and keeps provider documents and enrollments current.

The specialist independently manages complex credentialing and enrollment cases across payors, provider types, and jurisdictions; resolves documentation and system discrepancies; maintains provider participation and regulatory records; and supports quality reviews, audits, issue resolution, and process-improvement projects. The role also provides technical guidance to credentialing staff and authoritative support to providers, payors, internal departments, and external partners. Records must be complete, accurate, confidential, and audit-ready.

Requirements

• High school diploma or GED.
• Eight or more years of progressively responsible credentialing, provider enrollment, or enrollment maintenance experience in a hospital, physician office, health system, or managed care setting.

Nice To Haves

• Associate degree in healthcare administration, business administration, health information management, or a related field.
• CPCS (Certified Provider Credentialing Specialist) certification.
• Experience handling complex cases, escalations, quality review, regulatory maintenance, or staff guidance.

Responsibilities

• Independently manage complex credentialing and enrollment applications from receipt through completion across multiple payors, provider types, and jurisdictions.
• Analyze nonstandard requirements; resolve complex documentation or system discrepancies; and coordinate corrective action with providers, internal departments, payors, and external entities.
• Complete and validate CAQH, Cactus, paper and electronic applications, spreadsheets, and payor portal records for accuracy, completeness, and compliance.
• Manage high-risk or time-sensitive cases, establish follow-up plans, and communicate material barriers and resolution status to leadership.
• Manage complex provider terminations and updates to practice locations, participation records, taxonomy, specialty, demographics, licensure, DEA, malpractice, and related information across payors and systems.
• Coordinate complex hospital affiliation and privileging activities, including appointments, reappointments, and required maintenance documentation.
• Complete and resolve state-specific Medicare and Medicaid maintenance, revalidations, recertifications, and related regulatory updates.
• Identify cross-system or multi-payor inconsistencies, determine corrective action, and ensure supporting records are complete and audit-ready.
• Review credentialing and enrollment maintenance work for accuracy, completeness, timeliness, and compliance with payor, regulatory, and departmental requirements.
• Identify recurring defects, document findings, support audit requests, and recommend corrective training or controls.
• Investigate complex participation, location, affiliation, regulatory, and enrollment maintenance issues; identify root causes; coordinate resolutions; and recommend actions when requirements conflict or procedures do not address an issue.
• Lead or support workflow improvement, data integrity, system cleanup, implementation, and other high-impact departmental projects.
• Evaluate process gaps, recommend standardized controls and documentation updates, and monitor whether changes produce the intended result.
• Provide technical guidance, coaching, and workflow support to credentialing staff while reinforcing procedures and quality expectations.
• Serve as a subject matter resource for assigned payors, systems, regulatory programs, or maintenance functions and assist leadership with knowledge transfer and cross-training.
• Provide timely and accurate support to providers, payors, internal departments, and external partners on complex credentialing and enrollment matters; communicate risks, requirements, decisions, and resolution steps clearly.
• Maintain complete, accurate, confidential, and audit-ready records for assigned work and advanced case activity.
• Provide operational coverage and perform other duties consistent with the senior scope of the position.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED