Utilization Review Clinician - ABA

UnitedHealthcare, Cigna, and Centene launch shared credentialing program. By Salsabila Hartanti September 26, 2026 Three major health insurers, UnitedHealthcare, Cigna, and Centene, have partnered to streamline provider credentialing through a unified external platform. CertifyOS, the developer, says its system could erase three-quarters of a $2 billion annual administrative cost. On September 23, CertifyOS unveiled its National Shared Credentialing Program, identifying these three insurers as its inaugural participants, according to a company press release. The platform is scheduled to launch this fall. Streamlining verification processes. In this model, participating insurers submit their recredentialing lists to CertifyOS, which conducts primary source verification adhering to National Committee for Quality Assurance and Medicaid standards across all states where a clinician holds a license. Clinicians, including physicians, input their CAQH ID and necessary details once via the CertifyOS portal, eliminating the need to engage with each insurer separately. CertifyOS CEO Anshul Rathi stated in an interview with Fierce Healthcare that between 1.4 million and 2 million providers are expected to complete credentialing through the platform in the coming year. Mike Kane, senior vice president of provider data operations at UnitedHealthcare, commented in the announcement that this approach would "allow providers to spend more time focused on patient care." The argument is based on CertifyOS's calculations, which estimate that the U.S. spends more than $2 billion a year verifying provider credentials and that as much as 75 percent of that is avoidable. The company puts plans' cost at $200 to $500 per provider per recredentialing cycle and says providers file an average of 17 applications a year, worth roughly $700 in time and effort. The press release does not specify the source of these figures. Impact on medical practices. For medical practices, credentialing is a revenue problem before it is a paperwork problem. A provider who is not credentialed with a plan cannot bill it, and new-patient schedules for a new hire often wait on those approvals. A Nov. 4, 2025, MGMA Stat poll found 65 percent of medical groups had credentialing and reappointment files on time, while 32 percent reported a backlog, a credentials verification organization delay or a slip into the next quarter. Respondents traced most backlogs to payer enrollment delays and slow reference and board verifications. There is no practice-side sign-up. Plans roster providers with CertifyOS, and CertifyOS reaches out. Practices should keep every clinician's CAQH profile current. CAQH asks providers to reattest every 120 days, or 180 days in Illinois. Before sharing credentials, practices should verify CertifyOS requests with their UnitedHealthcare, Cigna, or Centene provider representative. Practices should also log how long recredentialing takes with these three plans today to assess whether the new system improves efficiency.

WellCare leadership transition marks major Centene shift. The WellCare leadership transition in North Carolina marks the end of a long chapter for Centene as Troy Hildreth departs after more than two decades with the organization. Hildreth, most recently president of WellCare of North Carolina, said he is shifting his attention toward advisory, board and consulting opportunities. His departure comes months after WellCare of North Carolina merged with Carolina Complete Health as Centene reorganized its government-sponsored health plan operations in the state. The timing makes the leadership change particularly notable because the merged organization is now moving forward under the Carolina Complete Health brand and a provider-led operating model. WellCare leadership transition ends long tenure. Hildreth spent more than 20 years with WellCare and Centene, according to his announcement cited by Becker's. He joined WellCare in 2004 and was named state president for North Carolina in 2019 after serving in corporate business development and strategy roles. Over his tenure, he became one of the organization's most visible leaders in the state. As plan president and CEO, Hildreth oversaw WellCare's involvement in North Carolina Medicaid and broader government-sponsored healthcare programs. His role also included participation in efforts involving behavioral healthcare integration, health equity and community partnerships. WellCare leadership transition follows merger. The most important strategic development preceding his departure was the combination of WellCare of North Carolina with Carolina Complete Health. Centene announced the merger in April 2026 after regulatory approval, saying the combined organization would operate under the Carolina Complete Health name and serve more than 980,000 members across Medicaid, Medicare and the Health Insurance Marketplace. The organization also supports North Carolina's Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans, which serve approximately 240,000 people with complex behavioral health, substance use and developmental-disability needs. At the time, Hildreth publicly supported the transaction and described it as an opportunity to expand the benefits of provider-led care across the state. Provider-Led model becomes central strategy. Carolina Complete Health differs from many conventional health plans because providers participate directly in its governance. The organization was established through a partnership involving Centene, the North Carolina Medical Society and the North Carolina Community Health Center Association. Local physicians participate in determining clinical policy and guiding decisions intended to improve care coordination and outcomes. Centene has positioned this provider-led structure as an important feature of the combined organization. WellCare leadership transition reflects consolidation. The merger effectively consolidated two Centene-affiliated North Carolina organizations that had previously operated under separate brands. Centene said combining their capabilities would strengthen provider relationships, community partnerships and coordinated care while allowing members to retain access to their existing benefits and provider networks. Chris Paterson, Ph.D., chief executive officer of Carolina Complete Health, became CEO of the combined organization. That leadership structure meant the merger already represented a significant organizational transition before Hildreth's subsequent departure. Hildreth oversaw major North Carolina initiatives. During Hildreth's leadership, WellCare participated in several initiatives extending beyond insurance administration. In 2024, WellCare of North Carolina achieved NCQA Health Equity Accreditation ahead of the state's expected deadline. Hildreth described the achievement as part of the plan's broader effort to reduce health inequities and improve quality across its membership. The organization also invested in community-based programs addressing social factors that influence health. In 2025, WellCare announced more than $1.6 million in investments across over 40 North Carolina nonprofits, supporting areas including food, housing, utilities, clothing and interpersonal safety. Community partnerships became part of strategy. WellCare and the Centene Foundation also committed $1.95 million toward The Umbrella Center in Charlotte, a family justice center supporting people affected by domestic violence, sexual assault, child abuse, elder abuse and human trafficking. These initiatives illustrate how Centene's local health plans increasingly combine insurance operations with community investment and social-care strategies. Hildreth was frequently involved publicly in communicating that approach. North Carolina remains important to Centene. Centene continues to maintain a substantial presence in North Carolina despite the organizational changes. The company reports operations in Raleigh, Asheville, Charlotte, Greensboro, Greenville and Lumberton, with 1,763 employees in the state as of June 30, 2026. Carolina Complete Health currently serves more than 750,000 Medicaid members statewide and supports more than 240,000 Tailored Plan members. Centene also continues to market Wellcare-branded Medicare products in North Carolina, covering more than 12,000 Medicare members through Medicare Advantage and prescription drug offerings. This distinction is important because the WellCare of North Carolina Medicaid organization has been consolidated into Carolina Complete Health, while the Wellcare name continues to exist within Centene's broader Medicare business. Leadership change comes during payer transformation. The North Carolina transition also occurs while Centene continues adjusting its leadership and organizational structure nationally. The company announced a new executive leadership structure in April 2026, part of a broader effort to align operations around government-sponsored healthcare and local market execution. Health insurers increasingly face pressure to simplify organizational structures while managing Medicaid redeterminations, Medicare Advantage economics, regulatory requirements and rising medical costs. Within that environment, consolidating local health plan operations may create opportunities for administrative efficiency while preserving local provider relationships. WellCare leadership transition opens new chapter. Hildreth has not announced another full-time corporate position. Instead, he said he plans to pursue advisory, consulting and board opportunities following his departure. His exit closes a lengthy career chapter spanning more than two decades with WellCare and Centene and seven years leading the North Carolina plan. For Centene, the WellCare leadership transition arrives as its North Carolina strategy moves decisively toward Carolina Complete Health's provider-led model. The next phase will test whether the combined organization can translate greater scale into stronger provider coordination, member experience and community impact while managing nearly one million members across multiple government-sponsored insurance markets. The departure therefore represents more than a routine executive move. It marks the completion of one leadership era as Centene integrates two major North Carolina health plan businesses under a single operating structure.