Credentialing Corner

# What does a Medical Credentialing Specialist do?

- June 22, 2023
- Posted by Kristen Edwards

22 Jun

Medical credentialing specialist works to verify the credentials of providers that help maintain regulatory compliance. However, there might be no mandatory education for becoming a credentialing specialist but having a bachelor’s or associate degree in medicine to know the terminology, healthcare administration, information management, or a related field.

This will help in achieving any administrative or front desk role in a medical facility as a contracted or hired medical credentialing specialist. Keep reading to learn about credentialing specialists and questions you might have about medical credentialing specialists.

## Responsibilities:

A medical credentialing specialist has a range of responsibilities in the healthcare industry. To understand them better, let’s dive deep into them separately;

### Verify qualifications and credentials:

A medical credentialing specialist review education, licensure, state documents, and academic receipts meticulously and verify them comprehensively to make sure that they are capable of performing quality healthcare. The credentialing process enables a provider to maintain the standard of care and meet the regulatory requirements.

### Conduct background checks:

Credentialing specialists also perform background checks on healthcare professionals and providers to make sure their integrity and suitability for practice remain constant. They may closely check facts, examine criminal records, review malpractice claims deeply, disciplinary actions, and other relevant information provided.

### Monitor compliance:

Another responsibility of credentialing specialists is ensuring that every healthcare provider they credentials comply with relevant laws, regulations, and industry standards. They must verify ongoing compliance with licensure and continuing education requirements.

### Maintain credentialing databases:

Credentialing specialists maintain up-to-date and accurate databases, which contain the credentialing information and data of healthcare providers. This includes insurance coverage, certification, managing documentation related to licenses, and other pertinent details.

### Coordinate with organizations and agencies:

Medical credentialing specialists as a professional work with various healthcare organizations and agencies already and wish to get involved in the credentialing process. This may include insurance companies, healthcare facilities, government entities, and accrediting bodies.

### Stay updated with industry changes:

Another reason to hire a credentialing specialist is that they stay informed about accreditation standards, evolving regulations, and industry best practices. They adapt their procedures accordingly to maintain compliance and uphold quality standards.

### Assist in provider enrollment:

Also, these specialists support providers and healthcare practitioners in the enrollment process with government programs, insurance networks, and other entities. They help providers navigate the necessary paperwork and requirements.

### Ensure patient safety and quality care:

Among these range of responsibilities, the objective of medical credentialing specialists is to protect patient safety and making sure of high-quality care and timely delivery. By verifying credentials and monitoring compliance, they contribute to maintaining a trustworthy and reliable healthcare system.

## The key responsibilities of a Medical Credentialing Specialist

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Medical credentialing specialists don numerous responsibilities to smoothen out the healthcare function and contribute to improving the efficacy of the healthcare system. Here are some of the key responsibilities that healthcare credentialing specialists;

### Credentialing application processing:

Medical credentialing specialists meticulously process credentialing applications submitted by healthcare providers. They review the application forms, verifying the accuracy of the information provided and ensuring all required documents are included.

### Verification of education and training

Whether licensure or academic papers, one of the crucial tasks of a private credentialing specialist is to validate the training and educational qualifications of healthcare providers. Through validation, they ensure that the postgraduate training, medical degree, and any specialized certifications mentioned in the application by the provider are legitimate and up-to-date.

### License verification

In order to practice in a field of medicine, providers must hold valid state licenses to run their facility or to work under one. Medical credentialing specialists perform thorough verification of the status and authenticity of the licenses claimed by providers.

### Professional experience assessment

Another responsibility is assessing the experience of healthcare providers by reviewing their references, employment history, and any relevant documentation. This step helps identify the expertise and competencies of the providers and ensures they comply with the standards required by healthcare organizations.

### Review of malpractice history

This is crucial to maintain patient safety. Medical credentialing specialists conduct a comprehensive review of the malpractice history of practitioners and medical providers. This step helps identify any past disciplinary actions or malpractice claims or make sure that patients are not put at risk by providers with a history of misconduct.

### Ongoing monitoring and re-credentialing

How long does the credentialing process take? Medical credentialing is not a one-time process. Credentialing specialists continuously monitor the credentials to ensure that they remain in good standing. They facilitate the re-credentialing process, which involves regularly updating and re-evaluating providers’ credentials.

## How to become a Credentialing Specialist?

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Now that you are aware of all the duties, you should hunt for particular talents and credentials if you think being a credentialing specialist is your area of interest. A thorough guide for pursuing a profession in this area is provided below:

Now that you know all the responsibilities, if you think becoming a credentialing specialist is your field of interest, you should look for specific skills and qualifications. Here is a step-by-step guide on how to pursue a career in this field:

- Obtain relevant educational background: Get a bachelor’s degree in a field relating to your interests, such as healthcare management, healthcare administration, or an equivalent field, to start out on your career path. You can be thoroughly aware of the healthcare sector and its ins and outs if you have the necessary training and knowledge of healthcare administration.
- Obtain hands-on experience: You need to get along with the credentialing professionals and work for credentialing-providing organizations to gain practical experience if you want to become a healthcare credentialing expert. As a result of this interaction, you will have better proficiency with the protocols and requirements for certified healthcare practitioners.
- Gain knowledge of medical terminology and regulations: A credentialing specialist must be familiar with healthcare terminology and standards before entering the profession of medical credentialing. Being up to date on trends, healthcare compliance requirements, accreditation requirements, and changes to insurance plans is also advantageous in this industry.
- Obtain licenses and certifications: To prove your commitment to the industry and medical knowledge, think about obtaining the required training and certifications. Healthcare organizations like the National Association of Medical Staff Services (NAMSS) offer certification programs for professionals pursuing medical credentialing, such as credentialing specialists.

## Conclusion

In the ever-growing field of the healthcare industry, medical credentialing specialists play a vital role that cannot be understated. These credentialing professionals diligently validate and assess healthcare providers’ qualifications, backgrounds, and education to ensure patient safety and quality care. By upholding the highest standards, medical credentialing specialists contribute to the trustworthiness and integrity of the healthcare industry as a whole.

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