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Credentialing Specialist Career Guide

If you are a detail-oriented person who likes working with people, a career as a credentialing specialist may be a good fit for you. Credentialing specialists work with health care organizations. They make sure that doctors and health care facilities comply with relevant standards and regulations.

A credentialing specialist prepares and keeps reports of credentialing activities like accreditation, membership, or facility privileges and makes sure the applications meet federal, state, and local guidelines. Health care facilities and insurance groups are a few of the workplaces that need credentialing specialists. Credentialing specialists need to stay on top of any changes to credentialing guidelines and make sure all records and applications are up to date.

Also, credentialing specialists often must stay in contact with staff and insurance companies to make sure they have all the documents they need and to let them know about any changes to contracts, guidelines, and policies. Credentialing specialists should be familiar with word processing and spreadsheet programs, as they are essential to performing the duties of this position.

Sample job description

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

Preferred qualifications

  • 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

Typical work environment

A credentialing specialist will be tasked with ensuring that healthcare facilities and professionals are following the proper regulations and policies and are credentialed properly. These professionals must have excellent interpersonal skills and an excellent understanding of the latest state and national medical policies. A good understanding of various computer programs and basic computer troubleshooting may be beneficial, as the majority of work done by credentialing specialists is through the computer. These specialists will be tasked with keeping records of the latest insurance, credentials, and certifications, and updating specialists when there are any notable changes in policies or regulations. Ideally, credentialing specialists must understand various aspects of the medical field and be able to keep up to date with information accurately and efficiently. This position often will be in an office or clinic environment. The position will likely be full-time.

Typical hours

Most credentialing specialists work from 9 AM to 5 PM, Monday through Friday. However, some who work in facilities that are open 24 hours a day could work other shifts.

Available certifications

A credentialing specialist can have certificates that will prove useful to their field. Some of the relevant certificates to this position may be:

  • 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.

Career path

Credentialing specialists can often find work with a high school diploma or the equivalent. Candidates who have associate, bachelor’s or master’s degrees in a field like health information management are often more attractive to employers looking to fill credentialing specialist positions. Students are encouraged to take courses in subjects like medical terminology, health care procedures, legal requirements, and insurance processing while they are in school.

After three years in the field, credentialing specialists can apply for certification from the National Association of Medical Staff Services. The skills used and learned in the credentialing specialist field can also be applied to other careers like human resources, insurance underwriting, and community service management.

US, Bureau of Labor Statistics’ job outlook

SOC Code: 29-9098

2020 Employment81,400
Projected Employment in 203089,900
Projected 2020-2030 Percentage Shift 11% increase
Projected 2020-2030 Numeric Shift8,600 increase

According to the National Association of Medical Staff Services, credentialing specialists and other medical staff professionals should be aware of and ready to adapt to the increasing digitization of their field. More credential application programs and databases are being moved online and into the cloud, and the ability to work with those systems will be essential for credentialing specialists in the years to come.

Also, many health care companies are consolidating facilities, which is leading to all health care staff workers taking on a wider array of responsibilities. Another trend credentialing specialists should stay on top of is the increased use of telemedicine. More health care providers are seeing patients remotely, and that could change insurance and accreditation guidelines.