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The Bare Minimum - What to Expect from Your Credentialing Specialist

What should you expect from a credentialing specialist?


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We've talked about what a credentialing specialist's role is in the credentialing process. Doing the credentialing in-house can end up costing you if your staff is inexperienced. So, it's important that you hire a specialist who will help you streamline your process to maximize efficiency.


Meeting these expectations is (in my opinion) the bare minimum for a credentialing specialist. Their role is critical in maintaining the quality of healthcare services, ensuring patient safety, and supporting the financial stability of healthcare organizations. By recognizing and valuing the work of credentialing specialists, providers and investors can contribute to a more efficient and trustworthy healthcare system.


Comprehensive Verification of Credentials

At the core of a credentialing specialist's duties is the thorough verification of a provider's credentials. This should be done before a specialist submits any applications. Doing this first will cut down on delays due to inaccuracies and outdated information.

This process involves:

  1. Education Verification: Confirming the completion of medical school, residencies, and any fellowships.

  2. Licensure Validation: Ensuring that the provider holds current and valid medical licenses.

  3. Board Certification: Checking if the provider is board-certified in their specialty.

  4. Work History Verification: Scrutinizing the provider’s work history to identify any gaps or discrepancies.

  5. Background Checks: Conducting background checks to uncover any criminal history or malpractice claims.

  6. Information Verification: Confirming the provider's information is up-to-date and accurate on their NPI, CAQH, Availity, and other critical sites/portals used in the credentialing process.

This meticulous process is fundamental to ensuring that providers are qualified to deliver high-quality care.


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Timely and Accurate Application Management

Credentialing specialists are responsible for managing the entire application process for healthcare providers seeking to join insurance networks or hospital staff.

This includes:

  1. Application Preparation: Completing and submitting all necessary forms and supporting documents accurately.

  2. Follow-Up: Regularly following up with insurance companies and hospitals to track the status of applications.

  3. Problem Resolution: Addressing any issues or discrepancies that arise during the application process swiftly and efficiently.

  4. Information Access: Giving the provider access to their information at all times and provide the status of each application and where it's at in the credentialing process.

Timeliness and accuracy in these tasks prevent delays in provider enrollment and ensure continuous patient care and revenue flow.



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Regulatory Compliance

Credentialing specialists must have a deep understanding of the regulatory requirements governing healthcare provider credentialing. This includes:

  1. State and Federal Regulations: Staying updated with the changing laws and regulations at both state and federal levels.

  2. Accreditation Standards: Ensuring compliance with standards set by accrediting bodies such as The Joint Commission (TJC), the National Committee for Quality Assurance (NCQA), and others.

  3. Insurance Requirements: Understanding the specific credentialing requirements of various insurance companies in each state.

Compliance with these regulations is crucial to avoid legal penalties and to maintain the integrity and reputation of the healthcare institution.


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Communication and Interpersonal Skills

Effective communication is a vital part of a credentialing specialist's role. They must:

  1. Liaise with Providers: Clearly explain the credentialing requirements and process to healthcare providers. Be able to answer questions about the process and any issues that come up.

  2. Coordinate with Payers: Effectively communicate with insurance companies to facilitate smooth credentialing.

  3. Collaborate with Internal Teams: Work closely with the provider's staff to ensure all credentialing information is up-to-date and accurate.

Strong interpersonal skills help in building trust and maintaining positive relationships with all stakeholders involved.



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Continuous Monitoring and Re-Credentialing

Credentialing is not a one-time event. If you hire a specialist to continuously monitor your credentials to ensure ongoing compliance here's what you should expect:

  1. Regular Updates: Keeping provider information current and verifying any new qualifications or certifications.

  2. Re-Credentialing: Conducting periodic re-credentialing to maintain up-to-date records and compliance with accreditation standards.

  3. Alert Management: Setting up systems to receive alerts about expiring licenses or certifications and taking proactive steps to renew them.

Continuous monitoring helps in identifying and mitigating risks associated with provider qualifications and performance.


Ultimately, honest communication, comprehensive education, and the provision of reliable information are fundamental to the role of a credentialing specialist. These elements are essential for ensuring accuracy, maintaining trust, and upholding the highest standards in every aspect of the job.


Keep in mind that no one is perfect, myself included. There are times when I become so engrossed in my work and follow-ups with insurance companies that I may forget to send a reminder or provide an update to a client. Mistakes are a part of being human, so it’s important to strike a balance between setting expectations and extending grace.


Do you agree with this list? What would you add or take away from the bare minimum?



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