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Hiring a Credentialing Specialist

Why does it matter who you hire?

When it comes to credentialing, what do you look for in a credentialing specialist? Are you just looking for someone to get it done? After all, it's just filling out an application, right? Realistically, there's more to the credentialing process than just filling out an application, and that's why it's wise to choose an excellent credentialing specialist. Refer to the article The Credentialing Process to understand more about what it entails. Here are a few crucial responsibilities of a credentialing specialist.


  1. Collect and verify provider credentials: This includes reviewing education, licensure, certifications, and malpractice history to ensure they are correct for the provider's specialty and up to date.

  2. Maintain provider files: This includes keeping track of all credentialing documents and ensuring they are current. Updating and maintaining the provider's NPI, CAQH, Avalilty, and any other sites/portals needed for credentialing.

  3. Submit applications to payor organizations: This includes finding and completing the correct application to the correct insurance company. Providing supporting documentation as requested by the insurance company.

  4. Monitor provider compliance: This includes ensuring that providers are up-to-date on their continuing education requirements and not on sanctions lists. If documentation is set to expire during the credentialing process, it's a specialist's job to obtain the newest documentation from the provider and pass it on to the insurance companies.

  5. Resolve credentialing issues: This includes working with providers and payor organizations to resolve any problems that may arise during the credentialing process. Sometimes, there can be issues with the online software the insurance company uses, resulting in the application or extra documentation not processing correctly. The credentialing specialist might need to resubmit documentation in this case.


Identifying an excellent credentialing specialist is crucial for healthcare organizations to ensure the smooth onboarding and maintenance of qualified healthcare providers. Here are some key indicators to help you spot an excellent credentialing specialist:


Knowledge and Skills

  1. Knowledge of credentialing regulations: Credentialing specialists should understand credentialing rules, including those set by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission (TJC).

  2. Ability to navigate complex systems: Credentialing specialists must navigate complex systems and processes, such as Medicare's enrollment system and the National Provider Identifier (NPI) registry.

  3. Excellent communication and interpersonal skills: Credentialing specialists must be able to communicate effectively with both internal and external stakeholders, including providers, payers, and regulatory agencies.

  4. Attention to detail: Credentialing specialists must be able to pay close attention to detail and ensure that all applications are complete and accurate.


Professionalism

  1. Commitment to ethical standards: Credentialing specialists must be committed to ethical standards and uphold the highest standards of professionalism.

  2. Ability to work independently and as part of a team: Credentialing specialists must work independently to manage their caseloads, but they must also be able to work collaboratively with other healthcare insurance representatives.

  3. Problem-solving skills: Credentialing specialists must be able to identify and resolve problems that arise during the credentialing process.

  4. In addition to these green flags, credentialing specialists should be organized, efficient, and have a strong work ethic. They should also be able to adapt to change and work under pressure.

Here are some additional tips for identifying qualified credentialing specialists:

  1. Ask for references: Check with previous employers for feedback on the candidate's work performance.

  2. Conduct a thorough interview: Ask the candidate about their experience, knowledge, and skills. Do they know what Availity and other sites are used for? Can they explain the credentialing process to you?

  3. Assess the candidate's problem-solving skills: Give the candidate a hypothetical scenario and ask them how they would handle it.

  4. Ensure the candidate is a good fit for your organization: Consider the candidate's personality, work style, and values.



Here are some red flags that may indicate that you are working with the wrong credentialing specialist:

  1. Lack of experience or knowledge: A credentialing specialist should have a strong understanding of the credentialing process, including the requirements for different healthcare providers and the relevant regulations. If the specialist seems unfamiliar with these details or makes frequent errors, it could be a sign that they must be adequately qualified and experienced.

  2. Poor communication and responsiveness: A good credentialing specialist should be responsive to your inquiries and keep you informed of the progress of your application. If the specialist makes excuses, does not provide clear updates, or is difficult to reach, it could indicate a lack of professionalism or attention to detail.

  3. Unrealistic promises or guarantees: Credentialing can be complex and time-consuming, and there are no guarantees that your application will be approved. If a specialist makes promises that seem too good to be true, such as guaranteeing approval within a specific timeframe, it could be a sign that they are not being honest or transparent. The fate of your application is ultimately in the hands of the insurance company.

  4. Hidden fees or unexpected costs: The cost of credentialing can vary depending on the complexity of the application and the type of provider. However, an excellent credentialing specialist should be upfront about their fees and avoid surprises.

  5. Negative reviews or feedback: If you can find online reviews or feedback from other providers who have worked with the credentialing specialist, take some time to read them. Negative reviews or consistent complaints about similar issues could indicate that the specialist needs to be more reliable and trustworthy.

  6. If you are concerned about the quality of your credentialing specialist's work, consider seeking a second opinion from another specialist or consulting with an attorney.


 Once you've found a quality credentialing specialist, hang on to them! Don't forget to leave them a raving review and let them know they are appreciated. Leave a comment and share what you look for in a credentialing specialist.


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