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What Is the Job Description of a Credentialing Specialist?

Explore the career requirements for a credentialing specialist. Get the facts about education, job duties, and salary potential to find out if this is the right career for you.

What is a Credentialing Specialist?

Credentialing specialists work for healthcare organizations and ensure that physicians and healthcare facilities are in compliance with relevant regulations. They may also keep records related to insurance contracts and staff credentials. They often must keep in contact with staff and insurance companies to insure that they have all the necessary documents and inform them of any changes in contracts and policies. Because much of their work is done on computers, credentialing specialists must know how to use a variety of programs, including word processing and spreadsheet programs. The following chart gives an overview about what you need to know before entering this field.

Degree Required Associate's degree is typical; bachelor's and master's degree programs are available
Education Field of Study Health information management
Key Responsibilities Prepare reports, make certain that facilities and staff meet federal and state guidelines, assist auditors
Certification Optional certification available from the National Association of Medical Staff Services after completing three years of experience
Job Growth (2018-2028) 17% (for all medical and health services managers)*
Median Annual Wage (2019) $43,715**

Source: *U.S. Bureau of Labor Statistics, **PayScale.com

What Would I Do as a Credentialing Specialist?

As a credentialing specialist, you work at a healthcare facility, insurance group or similar organization to enforce regulatory compliance and quality assurance. Your job duties include preparing and maintaining reports of credentialing activities such as accreditation, membership or facility privileges. You ensure that all information meets federal and state guidelines when processing applications. For example, if a doctor requests admitting privileges at a hospital, you would process the application to make sure the doctor is eligible; then you would maintain all the records and documentation of the application and verification. You also keep a facility's accreditation up to date and assist auditors.

What Education Do I Need?

Most medical records specialists have an associate's degree, according to the U.S. Bureau of Labor Statistics (www.bls.gov). The Commission on Accreditation for Health Informatics and Information Management accredits degree programs in health information management at the associate's, bachelor's and master's degree levels (www.cahiim.org). In a 2-year associate's degree program, you study medical terminology, healthcare procedures, legal requirements and insurance processing.

What Qualifications Do I Need?

The National Committee for Quality Assurance (NCQA) has developed one of the most commonly used guidelines for health care quality, including the documentation of facility and provider credentials (www.ncqa.org). You should be familiar with NCQA standards and how to apply them. You should also be proficient with computer systems, networks and software applications, such as word processors and spreadsheets. After gaining some experience in the field, you may choose to pursue the Certified Provider Credentialing Specialist professional designation from the National Association of Medical Staff Services (www.namss.org). You are eligible to take the certification exam after you have three years of experience, including during the year prior to taking the exam.

What Are Some Related Alternative Careers?

Some related careers include human resources managers, insurance underwriters and social and community service managers. Outside of the medical field, human resources managers work in companies and other organizations to ensure that employees are qualified and able to perform the jobs they are hired for. Like credentialing specialists, underwriters must have a knowledge of insurance policies and contracts. These professionals are responsible for reviewing insurance applicants to determine if they qualify for coverage. Social and community service managers manage social service programs and organizations, as well as those who participate in them.