Credentialing SpecialistJob Description, Salary, Career Path, and Trends
Credentialing specialists typically work for healthcare organizations and ensure that the physicians and healthcare facilities comply with regulations. They must have good communication skills as they often have to stay in contact with insurance companies regarding changes in contracts and policies. Credentialing specialists need to be proficient with a variety of relevant computer programs and have excellent attention to detail. As this role includes the preparation and maintenance of reports pertaining to such credentialing activities as accreditation, membership, or facility privileges, solid written communication skills are required.
The role of a credentialing specialist is an important one as they ensure that healthcare facilities and physicians are following federal and state guidelines and that medical doctors and nurses have the necessary licenses they need. They also maintain records of training and certifications for the medical staff. Credentialing specialists must be familiar with medical terminology, have solid research skills, and have exceptional organizational skills.
Sample job description #1
Currently seeking a highly motivated and professional Credentialing Specialist who is responsible for streamlining, communicating, and facilitating the onboarding and offboarding processes for all Emergency Medicine clinical staff. Additionally, the Credentialing Specialist will be responsible assisting in credentialing and re-credentialing EM providers with health plans, hospitals, and state and federal licensure, as well as provide support in scheduling providers, changing records, recording all custom hours, and compiling payroll and reporting information as needed.
Coordinate streamlined onboarding processes for all Emergency Medicine clinical staff
Facilitate all parts of the onboarding process by working with HR/Payroll, Medical Directors, Provider Support Team, Lifespan support staff, and IT to ensure new providers have the information and tools needed to successfully begin their role in the Emergency Department
Ensure new clinical staff are aware of their orientation schedule, and have completed all required onboarding tasks, new hire paperwork, and regulatory, policy & health compliance requirements to successfully meet their identified start date
Effectively document and report the status of each candidate during the hiring process
Escalate any issues to ensure deadlines are met
Serve as the main point of contact for the provider and answering, in a timely manner, any questions about the onboarding process
Prepare any orientation materials as needed to assist in Human Resources orientation
Request and submit necessary credentialing applications and information to attain hospital privileges or affiliations
Create and update NPI application for all physicians and APPs to include all provider numbers, if applicable
Assist Credentialing Manager with obtaining timely hospital privileges
Notifies Lifespan Risk Services, RIH/TMH, MSO, Human Resources, Provider Support Team, and Brown EM’s Billing and Coding Departments of Provider’s credentialing status
Track licenses and DEAs for approvals and expirations
Send monthly reminders for any expiring licenses or DEAs
Track ACLS/PALS certifications and inform providers when recertification is necessary
Track influenza vaccinations to ensure compliance with Lifespan’s policies
Prepare monthly credentialing invoice
Track and pull CMEs for physicians requiring reappointment
Track completion of APPs NetLearning, and notify of any outstanding modules prior to reappointment
Work with the Emergency Medicine Ultrasound Director to ensure all requirements are met for EUS credentialing both initial and reappointment
Associates Degree in Medical Office Procedures or related field required, or substantial related experience; Bachelor’s Degree preferred
Proficient in MS Office, Primarily Work, Outlook, Excel, and Access
Must be extremely detail oriented and able to multitask
Must be professional and have excellent interpersonal, customer service, and telephone etiquette skills
Must submit a background release form and demonstrate proof of being free from disqualifying information
Must have a driver’s license and access to an insured vehicle as some transportation may be required
Ability to handle confidential information in a professional manner. Thorough knowledge of compliance with state and federal laws, including HIPAA, required
Sample job description #2
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Essential job functions (includes but is not limited to)
Highly focused on the review of credentialing files and reporting to work with candidates and cross functional teams to obtain missing, incomplete, and expiring items
Maintain filing information for all candidates going through the credentialing/onboarding process
Driving initiative to expedite the onboarding process and minimizing the time in process
Regularly communicates with internal and external candidates via email and/or phone
Oversees regulatory compliance expectations for state and federal programs
Formulates criteria and workflows for candidates to follow to meet state and federal requirements to gain system access
Identifies and recommends improvements to workflows and processes to improve accuracy and efficiency
Specialized knowledge of Microsoft Excel required to perform daily inputs, building functions, sorting, and filtering large amounts of data and ability to generate data drive reports weekly and on demand
Maintain confidential records and data, including but not limited to sensitive security information, personnel contact information, background check submittal information and employer information
Uses Microsoft Outlook daily to perform administrative duties
Participates in collaborative meetings and may serve as point of contact for specific programs or platforms
Supports recurring internal and external audit of records
Applies concept of continuous improvement to develop new skills during changing initiatives
Adhere to all company and department employment policies regarding security and confidentiality
Knowledge, skills, and abilities
Analytical skills to receive, assemble, and report on data records
Extremely attentive to details
Possess a high level of self-motivation and energy, and work with minimal supervision
High organizational and time management skills
Highly developed oral and written communication skills
Fosters working relationships with leadership and other contract Points of Contact
Ability to support multiple team members and projects simultaneously and prioritize in a fast-paced environment
Proficiency in Adobe and/or FoxIt PDF as well as the Microsoft Office Suite which includes Word, Excel, PowerPoint, Outlook
Ability to work as part of a team with excellent interpersonal skills
Minimum 2 years credentialing experience
Bachelor’s or Associates degree preferred
Minimum 3 years working in a corporate office environment working with multiple internal and external customers
Sample job description #3
The Credentialing Specialist is responsible for all aspects of the privileging and credentialing process for all licensed clinician/providers of the center (i.e. physicians, physician assistants, ARNPs, dentist, dental hygienist, clinical counselors, etc.). In addition, this position is responsible for all communication leading toward insurance panel accreditation for staff and center.
Researches and processes new health plans applications for Center and its providers
Manages health plans enrollments, increasing plan acceptance/participation for Center and all providers using applicable software (i.e. OneApp Pro)
Provides consistent, accurate, and timely credentialing support for Center’s accreditation process
Acts as coordinator for furthering any and all Center’s wide certifications it may decide to pursue
Acts as internal resource around issues associated with public funding sources, such as Medicaid and Medicare, as well as private payors
Ensures Center and its providers take advantage of all the existing incentive initiatives through Medicaid and Medicare with the submission of the appropriate application
Provides accurate, timely and documented verification of the information provided by new applicants as well as current providers
Assists with the onboarding process of medical, dental and behavioral health services providers
Verifies, researches, and responds to telephone and written inquiries from providers and other departments, pertaining to provider participation and credentialing status
Works with medical and finance staff to ensure list of all current payers sorted by the number of patients within each group and all insurance carriers sorted by the type of product (Medicaid, Medicare, or CHIP), patient copay and fee schedule are kept and updated regularly
Regularly communicates to medical and finance staff on all health plans, enrollments, and updates
Coordinates all additions, terminations and changes to all plans as appropriate
Prepares and maintains reports on all accreditation and credentialing activities as required
Supports development (writing), implementation, and upkeep of all Center’s policies and procedures as needed
Assists to maintain Center’s specialty care network
In conjunction with Human Resources (HR) maintains compliance with documentation standards for verification of employee credentialing requirements, including but not limited to, licenses, certifications, registrations, permits, educational degrees, internship, residency and association memberships, and any related electronic systems and software.
In coordination with HR, ensures all required backgrounds and re-verifications are performed during hiring and thereafter. (i.e. National Practitioner Data Bank)
In coordination with HR, ensures all records are properly kept for all providers (i.e. the National Practitioner Data Bank, CAQH, and the Utilization Review Accreditation Commission)
Collects, enters and ensures data in the CAQH Universal Provider Data Source are updated
Participates in site visit(s) for credentialing purposes as well as programmatic audits as required
In conjunction with the Compliance Associate, ensures Center’s credentialing process fully complies with HIPAA and Joint Commission
Ensures that on-line trainings are current as required (MyLearningPointe and other trainings)
Participates in all safety programs which may include assignment to an emergency response team
Acts upon assigned role in Emergency Code System
Ensures proper hand washing according to Centers for Disease Control and Prevention guidelines
Minimum two years of experience managing credentialing, privileging, or similar healthcare professional verification and organization’s accreditation processes are required
Minimum 1 year of experience in health plan enrollments and management is required
Experience in insurance management is highly preferred
Credentialing Specialist (CPCS) preferred
Average salary and compensation
The average salary for a credentialing specialist is $44,500 in the United States. Position salary will vary based on experience, education, company size, industry, and market.
Los Angeles, California
Minneapolis-St. Paul, Minnesota
New York City, New York
Sample interview questions
What do you know about credentialing?
Are you confident in your ability to accurately assess and understand policies and procedures?
How many years of experience do you have as a credentialing specialist?
Do you have any relevant certifications for this position?
How would you resolve a change in policy and successfully update the relevant medical professionals?
What makes you think you’re a good fit for our company?
How important is it to keep the information confidential?
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