What Does a Credentialing Specialist Do?
Credentialing specialists typically work for healthcare organizations and ensure that 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.
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National Average Salary
Credentialing Specialist salaries vary by experience, industry, organization size, and geography. To explore salary ranges by local market, please visit our sister site zengig.com.
The average U.S. salary for a Credentialing Specialist is:
Credentialing Specialist Job Descriptions
When it comes to recruiting a credentialing specialist, having the right job description can make a big difference. Here are some real world job descriptions you can use as templates for your next opening.
New credentialing specialist needed at [Your Company Name] to oversee and verify credentials of local medical professionals. The credentialing specialist will be required to keep up to date with the latest state, local, and national policies and credentials. You must track medical professionals to ensure proper training, certifications, and experience. Your job responsibilities will include managing databases with information pertinent to this position as well as verifying the liability and eligibility of doctors in the facility. You must be competent with the latest procedures and medical policies in order to ensure facilities and professionals are properly credentialed and following accurate procedures. If chosen, you will work at [Your Company Name] full-time and have access to benefits. If you have a fantastic understanding of the latest medical policies, previous experience in this field, a strong work ethic, and the ability to properly record and supplement data, this position will be for you! Please consider applying. [Your Company Name] would love to have you on our team.
Typical duties and responsibilities
- Process initial credentialing and re-credentialing applications
- Screen practitioners’ applications and supporting documentation to ascertain their eligibility
- Present applications to the facility’s Credentialing Committee
- Assist customers with credentialing inquiries
- Reliably back up data
- Capture primary source documentation in computer databases
- Ensure compliance with applicable laws, regulations, procedures, and policies
Education and experience
This position requires a high school diploma or equivalent. 1+ years of credentialing experience with a hospital medical staff is preferred.
Required skills and qualifications
- Knowledge of medical credentialing and privileging procedures and standards
- Excellent verbal and written communication skills
- Proficient in Microsoft Office Word and Excel
- Ability to focus for extended periods
- Proficient in touch-typing
- Bachelors degree preferred
- Healthcare experience
- Excellent written and oral communication skills
- Computer literate with proficiency in web-based products and ability to learn new applications easily
- Attention to detail and accuracy
- Professional friendliness
We are 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 for 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 begin their role in the Emergency Department successfully
- 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
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 various 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 minimize 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 of credentialing experience
- Bachelor’s or Associates degree preferred
- Minimum 3 years working in a corporate office environment working with multiple internal and external customers
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 an 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 enrollment and management is required
- Experience in insurance management is highly preferred
- Credentialing Specialist (CPCS) preferred
Candidate Certifications to Look For
- Credentialing Specialist (CPCS) Online Certification Preparation Course. The credentialing specialist online certification preparation course is a course designed to prepare a credentialing specialist for the assessment test for the CPCS certification. This test is uniquely beneficial to credentialing specialists who are looking to expand their certifications and expertise in the field.
- Certified Provider Credentialing Specialist (CPCS). The preparation course is a predecessor to the certified provider credentialing specialist course, which is a uniquely challenging course that may vary depending on the location and proper policies this certification is required to cover. This certification is offered by the NAMSS and is widely recognized as the leading certification for a credentialing specialist.
How to Hire a Credentialing Specialist
There are a number of important initial considerations when hiring an accounting assistant:
- Recruiting: Do you have the knowledge, tools, and resources to attract and screen candidates?
- Complexity: Do you need a senior professional, or will mid or junior-level skills and experience suffice?
- Duration: Are you hiring for a project or an ongoing need?
- Urgency: How soon does the opening need to be filled? What happens while it remains open?
- Headcount: Do you have the budget and approval for an internal employee, or should you consider alternate options?
Answering these questions will help determine the best course of action for your current hiring need. Fortunately, great options exist for every scenario. These are our recommendations:
1. Use 4 Corner Resources (or another professional recruiting firm)
The heavy lifting is done for you when working with a top-tier staffing company like 4 Corner Resources. We source, screen, recruit, and deliver only the most qualified candidate(s), saving you significant time and effort throughout the hiring process while you remain focused on your core business. Understanding your needs and ensuring the right candidate for the position is the key to our success.
This is the best route to take when:
- You need to fill the position quickly
- You want access to a vast talent pool of high-quality, prescreened candidates
- Your position is suited for temporary hiring services, contract staffing, or contract-to-hire recruiting, and you intend to direct the work activity.
- You are hiring an employee as a direct placement but aren’t able to recruit effectively or efficiently with your internal staff.
- You aren’t familiar with current salary rates, market trends, and available skill sets
2. Advertise your opening on a top job board
Your best option may be to advertise your opening on a proven job board. There are many widely used job sites out there that draw visits from qualified candidates. If you have someone internally who can dedicate the time and energy to sort through applications and screen individuals effectively, this can be a great choice.
We recommend using a job board when:
- Your internal recruiting team has the knowledge and experience to assess candidate qualifications
- You are hiring a direct employee and have time to manage the entire recruiting effort
- You have a process for receiving, screening, and tracking all resumes and applications
- You are prepared to respond to all applicants
We recommend using CareerBuilder for credentialing specialist openings:
CareerBuilder has been a trusted source for hiring since 1995. Reach 80+ million unique, diverse U.S. job seekers annually by posting your jobs through their talent acquisition channels. Through CareerBuilder, you can engage candidates and drive them into your sourcing pipeline. We recommend using CareerBuilder for hiring when you have the internal resources and processes to review, screen, and reply to all applicants.
3. Leverage your internal resources
You can utilize your own website, social media, and employees to assist in your search for top candidates.
A company website posting should be the first step in notifying prospective candidates that you are hiring. Social media can also be a powerful tool for spreading the word about your new opening. As far as exposure is concerned, this option can be as good as some job boards when you have a large enough following across various platforms, like LinkedIn, Instagram, Facebook, TikTok, and Twitter.
Current employees are every organization’s greatest asset. Encourage your internal team to promote job openings to their network by offering cash and other incentives.
We recommend these options when:
- Your brand has great name recognition
- You can consistently monitor and respond to candidate activity through your website and social media accounts
- You have a process in place to quickly and broadly communicate job openings and requirements
- You have an effective employee referral program in place
If you aren’t sure which path is best, schedule a discovery call today with our seasoned recruiting professionals. The 4 Corner team is on standby to help you find the best option for your unique hiring need.
Sample Interview Questions
- As a credentialing specialist, what are your main responsibilities? What inspired you to become one?
- Would you be able to discuss your experience with managing provider databases and maintaining confidentiality and security of sensitive information?
- What steps do you take to make sure all credentialing activities are in compliance with laws and regulations, such as HIPAA?
- Can you tell us about a challenging credentialing scenario you navigated and how you resolved it?
- What methods do you use to communicate updates and status of credentialing processes with providers, healthcare facilities, and other stakeholders?
- Can you describe the credentialing process, including verification of education and professional certifications?
- What steps do you take to ensure that all credentialing data you collect is accurate, complete, and up-to-date?
- Could you share an experience in which you had to resolve a conflict or discrepancy in the credentials of a provider?
- How do you stay up-to-date with changes in regulations and requirements for provider credentials?
- How do you gather and verify the necessary information for credentialing with healthcare providers and other stakeholders?
- When dealing with a high volume of credentialing applications, how do you prioritize?