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.

Responsibilities

  • 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

Qualifications

  • 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

Our mission is to create a safe and simple future where identity verification is indisputable, and only you can assert your identity. We are a distributed company leveraging the latest technologies to deliver world-class products in the private and public sectors of finance, telecom, identity, security, retail, sports entertainment, commercial, government, and Iot. We use a variety of technologies and approaches to deliver quality product and services to government agencies and technology companies.

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

Qualifications

  • 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.

Responsibilities

  • 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

Duties

  • 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)

Safety

  • 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

Qualifications

  • 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.

LocationSalary LowSalary High
Phoenix, Arizona$44,250$59,850
Los Angeles, California$49,950$67,550
Denver, Colorado$41,600$56,250
Washington, DC$50,650$68,550
Miami, Florida$41,450$56,050
Orlando, Florida$38,200$51,650
Tampa, Florida$38,550$52,150
Atlanta, Georgia$40,450$54,750
Chicago, Illinois$46,500$62,950
Boston, Massachusetts$50,300$68,050
Minneapolis-St. Paul, Minnesota$40,050$54,250
New York City, New York$52,950$71,650
Philadelphia, Pennsylvania$43,150$58,350
Dallas, Texas$41,950$56,800
Houston, Texas$41,750$56,550
Seattle, Washington$48,400$65,500
National Average$37,850$51,150

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?
  • Are you skilled with computers?
  • Do you have knowledge of any medical software?

Credentialing Specialist Jobs in Ashburn

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