WHAT DOES A CREDENTIALING SPECIALIST DO?

Updated: Jan 12, 2025 - The Credentialing Specialist updates and maintains provider data within a database, promptly escalates issues for resolution, and reports on project progress. This role involves compiling and processing credentialing applications, ensuring compliance with health plan and regulatory requirements, and maintaining confidentiality in line with HIPAA guidelines. Meetings with Credentialing Leadership, inter-departmental coordination, and documentation of processes are integral parts of the position.

A Review of Professional Skills and Functions for Credentialing Specialist

1. Credentialing Specialist Duties

  • Privileges Management: Working with medical providers to obtain privileges at hospitals and/or military facilities.
  • Application Assistance: Assisting medical providers to ensure completion of hospital/facility applications.
  • Application Completion: Working with hospital/facility administration to ensure physician/provider applications are complete and able to work as contracted.
  • Verification Management: Obtaining verifications as requested, including license, education, and employment.
  • Security Clearance: Working with military and federal security teams to obtain clearance to access facilities.
  • Security Process Assistance: Assisting medical providers through the security process, including answering questions and providing tips for completing SF-85, SF-85P, and/or e-QIP.
  • File Maintenance: Maintaining medical provider personnel files and the CAQH database.
  • Database Management: Maintaining internal medical provider database and documentation, tracking license renewals, and other key factors.
  • Effective Communication: Communicating effectively and professionally with all medical providers, agencies of the federal government (VA, IHS), and various teaming partners.
  • Shift Preparation: Preparing medical providers for the first shift, including sending payroll information and reporting instructions.

2. Credentialing Specialist Details

  • Application Updates: Assist team with application updates in the database.
  • Issue Escalation: Escalate issues with the database as identified for prompt resolution.
  • Progress Reporting: Report progress routinely to management to ensure projects are completed successfully.
  • Credentialing Applications: Completing and processing provider credentialing applications.
  • Data Management: Compiling and maintaining current and accurate data for all providers.
  • Regulatory Knowledge: Maintaining knowledge of current health plan and agency requirements for credentialing providers.
  • Verification Provision: Providing credentialing and privileging verifications if applicable.
  • Confidentiality Adherence: Maintaining strict confidentiality and adhering to all HIPAA guidelines/regulations.
  • Meeting Attendance: Attend meetings scheduled with Credentialing Leadership, other NextCare Departments, and health plan representatives.
  • Process Documentation: Document processes and procedures.
  • Mission Alignment: Treat patients and co-workers consistent with the NextCare Mission Statement, Vision, Values, and Performance Standards.

3. Credentialing Specialist Responsibilities

  • Primary Source Verification: Perform primary source verification on all providers.
  • Credentialing Applications: Complete and submit credentialing applications for both providers and facilities.
  • File Maintenance: Maintain files with provider and facility credentials.
  • Billing Information: Obtain and supply information to correctly bill services.
  • Information Tracking: Track information and submit timely.
  • Application Coordination: Coordinate with Credentialing Representative I to update primary source applications every two years.
  • Re-Credentialing: Complete any re-credentialing applications for providers.
  • Group Applications: Complete and submit group applications for new locations or re-credentialing.
  • Notification Submission: Submit notification letters to plans for new locations or updates to facilities.
  • Team Assistance: Assist other members of the team.
  • CAQH Maintenance: Initiate and maintain CAQH files on all providers.

4. Credentialing Specialist Job Summary

  • Credentialing Processing: Process health plan enrollment/credentialing applications for physicians and allied health providers.
  • Paperwork Review: Review and analyze the provider’s returned paperwork to ensure the completeness of the information.
  • Issue Identification: Identify and flag adverse information received from materials completed by the provider for the purpose of conducting a special investigation.
  • Reporting: Report this information to the Credentialing Specialist for follow-up.
  • Follow-up System Maintenance: Maintain tickler system outside of the credentialing database for follow-up of outstanding paperwork and unanswered correspondence according to schedules designed to maintain department standards for application processing time.
  • Report Generation: Run weekly reports from the credentialing database to determine required follow-up with providers and health plans.
  • Data Entry: Enter contact and action notes into a credentialing database to maintain an accurate record of progress with health plans.
  • Database Maintenance: Maintain credentialing database and billing database, updating provider health plan identification numbers and other required database fields.
  • File Organization: Organize and maintain provider health plan files and information following confidentiality guidelines.
  • Information Sharing: Share updated information (e.g., address changes, updated licensing or certification documentation) received from the provider during the enrollment/credentialing process with the Credentialing Specialist for input into the credentialing database.

5. Credentialing Specialist Accountabilities

  • Public Relations: Employ public relations skills in a wide variety of contacts with internal and external sources for purposes of soliciting information essential to health plan enrollment/credentialing.
  • Relationship Management: Establish and maintain a professional working relationship with providers, outside office staff, internal staff, and health plan staff.
  • Clerical Support: Perform varied clerical/secretarial support functions.
  • Policy Compliance: Maintain compliance with all company policies and procedures.
  • Credentialing Intake: Oversee the intake of initial credentialing applications, preparing them for submission to start the PSV process on a daily basis.
  • File Preparation: Prepare provider records for the credentialing coordinator during daily PSV return files.
  • Data Entry: Provide data entry for all basic provider data.
  • Administrative Support: Provide administrative support to the Credentialing Committee.
  • Meeting Coordination: Ensure quorum for each meeting.
  • Agenda Preparation: Prepare agendas, record and transcribe credential committee minutes, and manage appropriate follow-up for the credentials committee.