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What does a credentialing specialist do?

Updated January 8, 2025
7 min read
What does a credentialing specialist do

Credentialing specialists are employed by healthcare organizations, primarily to make sure that medical personnel and health facilities maintain compliance with regulations. They keep a record of the medical practitioner's credentials and make sure that their licenses are updated and issued legally for their specialty. They have to inform the medical staff of the upcoming renewal dates of their license and advise them on how to keep their credentials updated. Potential new employees are also monitored and screened for their current and required licenses before getting hired. Applicants for this job must have excellent knowledge and understanding of health information management. They must also work on maintaining licensure and credentials while applying the governing rules and standards.

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Credentialing specialist responsibilities

Here are examples of responsibilities from real credentialing specialist resumes:

  • Establish rapport with all PCP offices, hospital personnel, and manage care representatives.
  • Manage and administer the programs CME accredit education programs/Conferences.
  • Ensure enrollment and participation with all organization contract managed care plans and perform Medicaid/Medicare provider enrollment.
  • Process and manage all requests and applications for CME certification and supervise activities relate to credentialing process.
  • Perform spot claims audits to ensure CMS compliance with ICD-9, HCPCS, CPT, and other requirements.
  • Maintain and track data for OPPE and FPPE according to hospital policy and regulatory requirements.
  • Determine appropriate CPT, HCPCS, and ICD10 codes for prior authorization requirements within the organization.
  • Maintain all provider applications on CAQH while continuously evaluating applications for completeness.
  • Detail spreadsheet information verifying hospital privileges, malpractice insurance, - DEA verification.
  • Design an OPPE system copy by many.
  • Resolve EDI kick-outs on claims return with provider re-instatement issues.
  • Maintain contracts with IPA groups, MSOs, hospitals and ancillary providers.
  • Monitor and research reports identifying practitioners for federal/state sanctions, OIG and board orders.
  • Coordinate with the quality department to facilitate ongoing professional practice evaluation (OPPE).
  • Help in the rehabilitation process of patient's assist daily living skills (ADLs).

Credentialing specialist skills and personality traits

We calculated that 10% of Credentialing Specialists are proficient in Patients, Customer Service, and Data Entry. They’re also known for soft skills such as Organizational skills, Interpersonal skills, and Writing skills.

We break down the percentage of Credentialing Specialists that have these skills listed on their resume here:

  • Patients, 10%

    Documented complaints registered by patients against doctors* Prepared packets for board meetings; reviewed and maintained applications and files for physician assistants

  • Customer Service, 8%

    Provide excellent customer service by listening to concerns, troubleshooting problems and responding to organizational and individual needs.

  • Data Entry, 6%

    Maintained credential database through ongoing data entry of practitioner updates with accuracy and in compliance of established integrity guidelines.

  • Primary Source Verification, 5%

    Performed primary source verification of physicians, allied health and other practitioners in accordance with departmental, accreditation and regulatory standards.

  • NCQA, 5%

    Reinforced NCQA guidelines to assure efficient credentialing and move to delegated credentialing Designed and implement the credentialing software system-CACTUS.

  • CAQH, 4%

    Enforced regulatory compliance and quality assurance by ensuring all provider information meets Massachusetts state guidelines when processing CAQH applications.

"patients," "customer service," and "data entry" are among the most common skills that credentialing specialists use at work. You can find even more credentialing specialist responsibilities below, including:

Organizational skills. The most essential soft skill for a credentialing specialist to carry out their responsibilities is organizational skills. This skill is important for the role because "secretaries and administrative assistants keep files, folders, and schedules in order so that an office runs efficiently." Additionally, a credentialing specialist resume shows how their duties depend on organizational skills: "combine excellent organizational skills with hands-on technical knowledge, superior memory for details and a strong work ethic. "

Interpersonal skills. Many credentialing specialist duties rely on interpersonal skills. "secretaries and administrative assistants interact with clients, customers, or staff," so a credentialing specialist will need this skill often in their role. This resume example is just one of many ways credentialing specialist responsibilities rely on interpersonal skills: "contributed interpersonal relation skills toward delivering exceptional customer service in addressing and resolving conflict situations. "

Writing skills. Another skill that relates to the job responsibilities of credentialing specialists is writing skills. This skill is critical to many everyday credentialing specialist duties, as "secretaries and administrative assistants write memos and emails when communicating with managers, employees, and customers." This example from a resume shows how this skill is used: "process clinical provider applications, including underwriting facilitation. "

All credentialing specialist skills

The three companies that hire the most credentialing specialists are:

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Compare different credentialing specialists

Credentialing specialist vs. Scheduler

A scheduler is responsible for arranging appointments and carrying out reminder calls and correspondence to anyone involved. In a company setting, it is also a scheduler's responsibility to coordinate with various departments and personnel to organize an accurate timetable that will consist of meetings, gatherings, deadlines, or other pressing matters. Furthermore, a scheduler must have attention to detail as one must perform bookkeeping tasks, fix scheduling issues or conflicts, and organize documentation. There are also instances where one must process orders or payments.

We looked at the average credentialing specialist salary and compared it with the wages of a scheduler. Generally speaking, schedulers are paid $334 lower than credentialing specialists per year.While the two careers have a salary gap, they share some of the same responsibilities. Employees in both credentialing specialist and scheduler positions are skilled in patients, customer service, and data entry.

These skill sets are where the common ground ends though. The responsibilities of a credentialing specialist are more likely to require skills like "primary source verification," "ncqa," "caqh," and "health professionals." On the other hand, a job as a scheduler requires skills like "medical terminology," "patient care," "home health," and "phone calls." As you can see, what employees do in each career varies considerably.

Schedulers tend to make the most money working in the construction industry, where they earn an average salary of $53,150. In contrast, credentialing specialists make the biggest average salary, $43,293, in the insurance industry.schedulers tend to reach similar levels of education than credentialing specialists. In fact, schedulers are 2.2% less likely to graduate with a Master's Degree and 0.0% less likely to have a Doctoral Degree.

Credentialing specialist vs. Surgery scheduler

A surgery scheduler is responsible for organizing medical information, coordinating with doctors and other health professionals, and reaching out to patients to inform them of scheduled medical procedures and appointments. Surgery schedulers perform clerical and administrative duties, such as processing patients' payments, verifying insurance details, and updating their account information on the database. They also monitor the adequacy of inventory for medical operations and create purchase requests as needed. A surgery scheduler must have excellent communication skills, especially in responding to patients' inquiries and concerns and resolving complaints.

A career as a surgery scheduler brings a lower average salary when compared to the average annual salary of a credentialing specialist. In fact, surgery schedulers salary is $6,427 lower than the salary of credentialing specialists per year.Only some things about these jobs are the same. Take their skills, for example. Credentialing specialists and surgery schedulers both require similar skills like "patients," "customer service," and "data entry" to carry out their responsibilities.

Each career also uses different skills, according to real credentialing specialist resumes. While credentialing specialist responsibilities can utilize skills like "primary source verification," "ncqa," "caqh," and "health professionals," surgery schedulers use skills like "medical terminology," "patient care," "surgical procedures," and "surgery scheduling."

On average, surgery schedulers earn a lower salary than credentialing specialists. Some industries support higher salaries in each profession. Interestingly enough, surgery schedulers earn the most pay in the health care industry with an average salary of $34,302. Whereas credentialing specialists have higher pay in the insurance industry, with an average salary of $43,293.surgery schedulers earn similar levels of education than credentialing specialists in general. They're 4.4% less likely to graduate with a Master's Degree and 0.0% more likely to earn a Doctoral Degree.

Credentialing specialist vs. Unit secretary

Unit secretaries are administrative workers in a medical facility, usually a hospital or a clinic. They are in charge of religious activities in the unit or department they are assigned to. They manage incoming and outgoing mail, phone calls, and even appointments. They handle filing and recording of the documents of the department. They also take minutes of meetings and ensure that action plans are followed through. Unit secretaries should be familiar with the individuals in the department. They should also be accustomed to the schedule of members of the unit. Unit secretaries should be organized, dedicated, and trustworthy.

An average unit secretary eans a lower salary compared to the average salary of credentialing specialists. The difference in salaries amounts to unit secretaries earning a $8,746 lower average salary than credentialing specialists.credentialing specialists and unit secretaries both have job responsibilities that require similar skill sets. These similarities include skills such as "patients," "customer service," and "data entry," but they differ when it comes to other required skills.

Some important key differences between the two careers include a few of the skills necessary to fulfill the responsibilities of each. Some examples from credentialing specialist resumes include skills like "primary source verification," "ncqa," "caqh," and "health professionals," whereas a unit secretary is more likely to list skills in "patient care," "medical terminology," "patient charts," and "physician orders. "

Unit secretaries earn the highest salary when working in the health care industry, where they receive an average salary of $31,531. Comparatively, credentialing specialists have the highest earning potential in the insurance industry, with an average salary of $43,293.Most unit secretaries achieve a similar degree level compared to credentialing specialists. For example, they're 2.7% less likely to graduate with a Master's Degree, and 0.2% less likely to earn a Doctoral Degree.

Credentialing specialist vs. Chiropractic assistant/receptionist

Chiropractic assistant/receptionists typically earn lower pay than credentialing specialists. On average, chiropractic assistant/receptionists earn a $6,830 lower salary per year.According to resumes from credentialing specialists and chiropractic assistant/receptionists, some of the skills necessary to complete the responsibilities of each role are similar. These skills include "patients," "hipaa," and "hippa. "

Even though a few skill sets overlap between credentialing specialists and chiropractic assistant/receptionists, there are some differences that are important to note. For one, a credentialing specialist might have more use for skills like "customer service," "data entry," "primary source verification," and "ncqa." Meanwhile, some responsibilities of chiropractic assistant/receptionists require skills like "front desk," "phone calls," "insurance verification," and "patient care. "

In general, chiropractic assistant/receptionists hold lower degree levels compared to credentialing specialists. Chiropractic assistant/receptionists are 5.4% less likely to earn their Master's Degree and 0.9% more likely to graduate with a Doctoral Degree.

Types of credentialing specialist

Updated January 8, 2025

Zippia Research Team
Zippia Team

Editorial Staff

The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

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