In the healthcare industry, providers need to maintain the highest standards in order to be legitimate for practicing medicine. In a group practice, providers’ credentials are also verified while hiring to ensure well-educated and experienced providers for patient care. Along with having necessary educational degrees and medical licenses, maintaining such credentials is also important and comes under credentialing.
Behind the scenes, credentialing specialists are responsible for such tasks. Credentialing specialists ensure that healthcare facilities meet regulations and policies. Such measures are necessary to render the best patient care, which enhances repute and patient care.
In this article, we will learn what a credentialing specialist is and what a credentialing specialist does. We will also discuss career opportunities, duties, and challenges for credentialing specialists in the healthcare field.
Understanding of Credentialing Specialists?
Credentialing specialists are professionals who verify healthcare providers’ credentials to check their legitimacy. They ensure that providers meet the healthcare standards and are qualified enough to provide medical care to the patients. They have two basic duties: verifying information and ensuring that healthcare is managing their credentials.
Generally, credentialing specialists verify the educational degrees, medical licenses, experience certificates, and training programs. Background checks for liability claims or criminal records are also part of the credentialing process.
What do we mean by maintaining credentials here? Actually, it is necessary for healthcare providers to keep their credentials and licenses active and take care of expiry dates. Credentialing specialists maintain credentials by monitoring expiration dates. They assist in the renewing and updating process as well. Also read this blog to know what is medical credentialing exactly?
What is a Credentialing Coordinator?
Unlike credentialing specialists, credentialing coordinators manage the administrative and logistic side of the credentialing process. They oversee the paperwork and develop communication between healthcare providers, credentialing committees, and regulatory boards. The credentialing coordinator schedules meetings, accepts credentialing applications, and clears the provider’s queries.
Initial scrutiny of the credentialing process to check compliance is also a part of the coordinator’s job. To work as a coordinator in the credentialing process, you need to get a bachelor’s degree in healthcare administration. Additional certifications like CPCS and CPMSM are required to become an expert in credentialing administrative tasks.
What does a Credentialing Specialist do?
Below is the detail of all tasks that are performed by credentialing specialists in the healthcare facility:
1. Credential Verification
A medical bachelor’s degree, medical state license, training certifications, and malpractice insurance are required as basic documents to practice medicine in the US. Credentialing specialists verify the legitimacy of these credentials. They check the status of credentials by primary source verification.
2. Background Check
For public safety and the best patient care, credentialing specialists check criminal records, malpractice claims, and disciplinary actions against the provider. In case of any negative finding, providers are rejected at once for practicing medicine.
3. Database Management
A medical bachelor’s degree, medical state license, training certifications, and malpractice insurance are required as basic documents to practice medicine in the US. Credentialing specialists verify the legitimacy of these credentials. They check the status of credentials by primary source verification.
4. Re-credentialing
Healthcare providers need to get themselves re-credentialed periodically to maintain healthcare standards. It is the duty of credentialing specialists to track records and send reminders to providers to update their information. After every specific time interval, re-credentialing providers ensure that they are still competent and skilled to render the best patient care.
5. Communication with Providers
Specialists facilitate providers by communicating and addressing their issues. During the credentialing process, objections and asking for additional documents are common. Specialists are kept in the loop to allow them to clear objections at once. They also communicate about the application process, compliance issues, and application status. Good communication makes the process smooth and efficient.
Educational Requirements and Career Path
Advanced degrees and certifications are not required to become a credentialing specialist. A basic degree and experience in medical credentialing are enough to get the job. Below are details of the education requirements:
Education
The two primary differences between CPT 99204 and CPT 99205 demonstrate the timeframe between the dialysis physician and the patient. For CPT 99204 (45 minutes of face to face) the physician takes face to face with the patient for minimum 45 min in case of CPT 99205 (60 minutes of face to face). This involves taking a medical history, performing an examination, and discussing a diagnosis and plan for treatment.
Knowledge
To practice as credentialing specialists, professionals must have a thorough understanding of the healthcare industry, verification processes, medical terminology, and healthcare regulations. To maintain standards, some associations offer certifications that specialists must take. These certifications are Certified Provider Credentialing Specialist (CPCS) and Certified Professional Medical Services Management (CPMSM). These programs enhance performance abilities and provide knowledge of credentialing.
Skills
Credentialing specialists strive for some skills which are required for successful operations. They need to develop these skills during their degree programs, certification programs, training sessions, and workshops to enhance their capabilities. Below are some vital skills:
- Attention in Detail
- Organizational Skills
- Communication
- Technical Proficiency
- Problem-Solving
- Knowledge of Regulations
Continued Education
Continuous education to remain updated with new rules and regulations is vital to meet the standards of healthcare. Professionals should attend seminars, webinars, and workshops and get insight from such events. These events enhance the knowledge about dealing with complex cases and managing multiple tasks efficiently.
Challenges Faced by Credentialing Specialists
High Workload
Credentialing specialists often face applications with missing information. This brings an administrative burden to send applications back to resolve objections and again accept them by providers to undergo the credentialing operation. Awareness and education for providers are necessary, making them compliant with credentialing rules and regulations.
Incomplete Documentation
In recent years, it has been reported that a great number of healthcare providers apply for credentialing within and outside of the US. This may be challenging for credentialing specialists to manage all applications in a short time. As they have many duties, they need to manage them all one by one within a short time. It is recommended that credentialing is obtained as soon as possible to lessen waiting time and enhance efficiency.
Regulatory Changes
New rules and regulations are introduced by healthcare organizations to increase industry standards and patient care. It is challenging for providers to remain updated with new policies and apply them in the credentialing process. As every new regulation needs changes in paperwork or process protocols, it takes time and effort, But credentialing specialists must take measures to comply with regulatory changes.
Tight Deadlines
Credentialing is a preliminary step for practicing and billing for medical services; therefore, it must be done quickly. These tight deadlines are hard to cover and put credentialing specialists at stake.
Conclusion
In the credentialing process, credentialing specialists have a significant place in dealing with all verification processes and protocols. But the question is, what is a credentialing specialist, and what is a credentialing coordinator? Credentialing specialists are professionals who verify the credentials of providers to ensure that they are educated and expert enough to render medical services. Coordinators deal with paperwork, setting meetings, and developing communication. When hospitals hire new providers or providers want to start their individual practice, then credentialing is the first healthcare standard. They need to undergo this operation to ensure legitimacy. So, read our blog to know why Credentialing is necessary?
Credentialing specialists verify educational credentials, background records, malpractice licenses, and training certifications. They also manage databases and re-credentialing. A bachelor’s degree in administration and some certifications are required to become eligible for a specialist job. A few challenges, like tight deadlines, regulatory changes, and high workload, can be areas of concern, but taking necessary measures for credentialing can help streamline the process.
FAQ - People Also Asks
Database management and detail-oriented skills are very important for credentialing specialists. Other notable skills are communication, collaboration, compliance, and organizational abilities.
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