What does a Credentialing Specialist do?

Credentialing specialists work in a wide variety of health-related industries. They typically are responsible for verifying the credentials of employees and providers. Many professionals in this role have a number of other responsibilities and a background in the medical office. Some jobs in this field require specific certifications and educational requirements.

A credentialing specialist can work in an insurance group or a healthcare facility or company, such as a hospital or ambulatory care company. This person works to ensure that his or her employer and all parties or companies the employer works with are in compliance with all regulatory standards. He or she verifies and processes all credentialing information through a strict vetting process. This process might include calling insurance companies, universities and certification boards as well as cross-checking all information against government-regulated databases. This position also typically works with internal and external auditors when his or her employer is going through its own accreditation process.

Other responsibilities of someone in this position include creating and maintaining important credentialing reports. These reports usually collect all information regarding accreditation, facility privileges and membership in associations or other groups. When collecting the information, the specialist has to cross-check it against government guidelines and apply the information when processing credentialing applications. An example of this is when a credentialing specialist who works for a hospital verifies a doctor’s education, certifications and work history to grant him or her admitting privileges.

Most employers look for a credentialing specialist who has a bachelor’s degree or at least a two-year associate’s degree. Along with the educational requirements, most credentialing positions require candidates to have worked in a medical office or environment in some capacity. They must be familiar with the industry standards and guidelines for documenting both provider and facility credentials. Other common requirements include basic computer knowledge and experience working in both spreadsheet and word processing programs.

After a credentialing specialist has worked in the position for at least 12 months, he or she may work to earn the Certified Provider Credentialing Specialist (CPCS) designation. This designation is required to be able to work as a medical credentialing specialist or in positions that manage certification and licensures of staff members. The certification is attained through groups such as the National Association Medical Staff Services, American Academy of Professional Coders, Board of Medical Specialty Coding and Professional Association of Healthcare Coding Specialists.