What Is a Credentialing Specialist?

Healthcare professionals need to meet stringent standards before they can practice — and continue to uphold them for as long as they treat patients. That means proving their education, licensure, certifications, and experience. And while these things are all easy enough to find on a physician’s CV, verifying them is important before authorizing them to work. It’s a job that falls to a credentialing specialist. 

What is a credentialing specialist? Well, as the name implies, they’re an expert whose primary role focuses on verifying the credentials of practitioners. Here’s a drill-down into credentialing specialists: who they are, what they do, and why they’re vital for compliance.

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What Does a Credentialing Specialist Do?

A credentialing specialist makes sure healthcare professionals meet the necessary qualifications to provide care. Their primary responsibility is to verify and assess the credentials of providers to ensure compliance with industry standards and regulatory requirements. That typically involves two distinct functions.

First, a credentialing specialist reviews and verifies the educational background, licenses, certifications, and work experience of a caregiver. They confirm that the information provided is accurate and up-to-date. This process involves contacting educational institutions, licensing boards, and previous employers to validate everything. They also conduct thorough background checks — including criminal record checks — to identify any potential risks or red flags that may impact patient safety

Second, they ensure healthcare professionals maintain their credentials by monitoring expiration dates of licenses and certifications. They then facilitate the process of renewing or updating credentials as required. This ensures that both caregivers and facilities remain compliant with all certifications and accreditations.  

Overall, credentialing specialists play a key role in maintaining the integrity of healthcare delivery and protecting patient well-being.

Credentialing Specialist Job Duties

What is a credentialing specialist’s primary function? The actual job duties of a credentialing specialist are many, and each is equally as important in ensuring physicians and other caregivers are able to practice responsibly. Here’s a quick breakdown of their core duties:

• Credential Verification. Credentialing specialists review and authenticate credentials, qualifications, licenses, certifications, and other relevant documents submitted by individuals or organizations. This ensures that the provided information is accurate and meets the required standards.
• Compliance Assessment. They ensure individuals or organizations comply with all legal and regulatory requirements. This may involve checking if licenses are valid, certifications are up-to-date, and professionals meet the necessary educational or training standards.
• Background Screening. Credentialing specialists conduct background checks on individuals to identify any criminal records, disciplinary actions, or other negative factors that may affect their eligibility or reputation. This step helps to ensure public safety and protect the interests of the organization.
• Database Management. They maintain comprehensive databases or records of credentialed individuals or organizations. This includes updating information, tracking expiration dates of licenses or certifications, and ensuring accuracy and confidentiality of data — all an ongoing part of compliance. 
• Accreditation and Standards. In certain situations, credentialing specialists may play a role in assessing organizations against established accreditation standards or industry-specific regulations. They evaluate policies, procedures, and practices to determine if they meet the required quality and safety standards.
• Communication and Collaboration. They work closely with providers and organizations to provide guidance on compliance. This involves responding to inquiries, staying up-to-date on credentialing requirements, and facilitating communication to resolve compliance issues.

In larger organizations, credentialing specialists are often part of compliance teams. There may be multiple credentialing experts on staff, depending on the breadth of practice and the number of individuals practicing. 

How To Become a Credentialing Specialist

To become a credentialing specialist, you typically need to follow a few key steps. Generally, a combination of education, demonstrable knowledge, and relevant experience lays the groundwork for a successful career:

• Education. Most employers prefer candidates with at least a bachelor’s degree in a related field, such as healthcare administration, health information management, business administration, or a similar discipline. That said, some organizations may consider candidates with an associate’s degree or equivalent work experience.
• Knowledge. It’s important for credentialing specialists to have a solid understanding of the healthcare industry, including knowledge of medical terminology, healthcare regulations, compliance standards, and accreditation requirements. This knowledge can be acquired through formal education, professional development or on the job.
• Experience. Prior experience in healthcare administration, medical staff services, health information management or a related field can be advantageous. Experience with credentialing processes, medical staff privileging and knowledge of relevant software or databases used in credentialing are valuable assets.

The requirements for credentialing specialists can vary depending on the employer, the specific role and the level of responsibility involved.

Credentialing Specialist Education and Qualifications

While not always mandatory, obtaining professional certification in healthcare credentialing can enhance job prospects and demonstrate a commitment to professional development. The National Association of Medical Staff Services (NAMSS) offers two specific certifications, which are widely recognized in healthcare:

• The Certified Provider Credentialing Specialist (CPCS) demonstrates proficiency in areas such as credentialing processes, legal and regulatory compliance, provider enrollment, and privileging requirements.
• The Certified Professional Medical Services Management (CPMSM) validates the expertise and knowledge of professionals in managing medical staff services, ensuring compliance with regulatory standards and maintaining high-quality patient care.

Technology Used by Credentialing Specialists

Managing credentials across a wide pool of providers is an arduous, ongoing task. For that reason, many credentialing specialists utilize a digital credentialing platform.

Learn more in this guide about the pressures of credentialing and how technology can help to speed up the process and make things simpler.

Credentialing software puts all provider documents in one centralized location, to simplify document management and eliminate the need for manual record-keeping. This not only saves time but also improves efficiency and reduces the risk of missing or misplaced documents. Additionally, software automates various aspects of the process, such as sending reminder emails to providers and conducting exclusion checks. 

Another significant advantage of credentialing software is real-time reporting and status check capabilities. By providing instant access to up-to-date information, software enables proactive decision-making and effective management of the credentialing process. 

In addition to these benefits, credentialing software can also interface with websites for state and federal regulatory agencies — such as the Office of Inspector General List of Excluded Individuals and Entities (OIG-LEIE) and the System for Award Management (SAM) — as well as payer portals, enabling efficient submission of necessary information, and simplifying the enrollment process with payers.

MedTrainer Empowers Credentialing Specialists

Credentialing specialists have an extremely important job — one that’s ongoing and essential for compliance. It’s important for healthcare organizations to enable their credentialing experts with software that helps them to not only stay up to date on credentialing duties, but also consolidate them. 

Explore how MedTrainer can help you transform your credentialing process, to empower your credentialing specialists and caregivers alike. Schedule a demo today!