The Comprehensive Guide to Credentialing Specialist

If you are a part of any healthcare practice, you must be familiar with the credentialing process. Healthcare professionals can not deliver their services to patients without passing the credentialing process. Their complete educational and professional background, certificates, licenses etc are verified and then they get the approval for their practice. This is the responsibility of credentialing specialists. They are the experts in this field as they can efficiently verify practitioners’ credentials. However, if you want to know more about what is a credentialing specialist and what are their main responsibilities that 

What does a credentialing specialist do?

Credentilaing specialists play a major role in maintaining the integrity of a health care system.

Credentialing specialists rectify the credentials of healthcare providers to ensure that they meet the standard requirements of the healthcare system and provide quality care to patients. They are part of the administrative staff of each healthcare organization. 

Verification from primary sources

They verify the education, training, skills and work history of the doctors and other medical professionals. They show the confirmation that the provided information is accurate and updated. For this, they contact the primary sources including educational institutes, previous professional organizations licensing boards etc. Moreover, credentialing specialists also check the criminal records so patients stay protected from any future mishap. In addition, they also review all the medical policies and efficiently process the contracts. Likewise, they also handle the audit reports to complete the validation process of healthcare professionals.

Compliance assurance

Another goal of verification is to ensure compliance with the rules and regulations of the healthcare industry. This provides benefits to both healthcare providers and patients. If their credentialing is done rapidly and accurately then patients get the care without any delay. Likewise, healthcare providers can also generate revenue. 

Database management

The credentilaing specialists not only verify the information of healthcare professionals but they also update the medical databases with the physician’s information related to their skills, training, licenses and certificates when there is a need to renew the credentials.

Accreditation and standards

Credentilaing specialists also perform the organisation; assessment against the industry-specific regulations. They also analyze the procedures, policies and complete practices to ensure that they meet the standards or not. 

Recredentialing

Other than verification, they also play a significant role in maintaining the credentials. They keep a regular eye on the expiration dates of certificates and licenses and then renew the credentials if required. 

Effective communication

Credentilaing specialists also have a major responsibility of communication with providers and healthcare organizations. They provide effective guidelines on compliance. They also respond to all queries on time. Moreover, if any compliance error occurs, resolving them is also in their

How to become a Credentialing specialist?

Education

If you want to become a credentialing specialist then you should have a degree and specialization in the related field. 

Experience

Individuals should have a complete professional background in the administration of the healthcare industry or a part of medical staff services or any other related field. The specific credentialing experience is considred more valuable.

Which professional certificates are present in healthcare credentialing?

 The National Association of Medical Staff Services (NAMSS) offer two specific types of certificates which are as follows:

Certified Professional Medical Services Management (CPMSM) 

The CPMSM verify the skills, knowledge and expertise of those experts who are providing the medical staff services so they are strictly adhered to the regulations standards or requirements and patients get supreme qulaity care. 

Certified Provider Credentialing Specialist (CPCS)

They have top expertise in the following areas:

• Credentilaing process
• Provider enrollment
• Legal and regulatory compliance

What is the importance of Credentialing specialists in Medical Billing?

There is a great significance of credentialing specialists in medical billing such as:

Billing accuracy 

Accurate credentialing is directly linked with billing accuracy. This indicates that only qualified and professional healthcare providers are billing for services. Moreover, this also results in a reduction in errors and claim denials and rejections from the insurance companies.

Streamlined operations

With the efficient management of the credentilaing process, healthcare professionals can make a controlled and structured flow of their operations within the healthcare facility. In this way, they can better focus on theur patients and strategies to increase their reimbursements.

Regulatory compliance

With the help of credentialing specialists, healthcare organizations comply with varied standard rules and regulations including the Joint Commission and Centers for Medicare & Medicaid Services (CMS). By ensuring compliance, they can stay secure from penalties or other related issues. 

Patients satisfaction

If patients are familiar with the provider credentialing then they remain satisfied that they are getting the best services without compromising on quality. They prefer to get the services whenever they need them and exhibit increased satisfaction and retention rates. 

What are the steps involved in the Credentialing process?

The process of credentialing in medical billing involves the following steps:

Gathering information

First, a credentilaing specialist collects information about the provider’s education, employment history certificates etc. 

Source verification

After getting the information, the provided information is verified from the primary sources to confirm that the providers are capable and skilled ad there is not any fraudulent case.

Assessment

The next step after the source verification is the credential evaluation to determine the eligibility for practice.

Recommendation

Based on the results, they make decisions such as giving or denying access to practice

Concluding Remarks

Credentialing specialists are an integral component of healthcare organizations specifically for medical billing services. They verify the information of healthcare providers so patients get uncompromised quality care. Moreover, this also boosts operational efficiency, develops the patient’s trust and ensures compliance. 

If you are looking for credentilaing services then you are at the best place. Outsource to Medstar for credentialing services and simplify your credentilaing process. To schedule a consultation with our credentialing experts and unlock the success of your healthcare practice.