What Is Credentialing Experience: From Novice To Expert

Sarah Jones
Credentialing expert at computer and smiling

Credentialing experts in healthcare are like the gatekeepers of a fortress. Just as a gatekeeper verifies the identity and purpose of everyone who enters the fortress, credentialing specialists rigorously verify the qualifications and backgrounds of healthcare providers before they meet with patients. This process ensures only qualified and competent professionals are allowed to provide care, safeguarding the health and well-being of patients — just as a gatekeeper safeguards a fortress.

Credentialers have very unique skill sets and should be highly valued by their organizations.


Look for these 10 attributes in a credentialing specialist.


What Does a Credentialing Expert Do in Healthcare? 

Credentialing teams gather and validate healthcare providers’ qualifications, licenses, and certifications. Their meticulous verification ensures that all practitioners adhere to the rigorous standards of medical boards and healthcare regulations.

Credentialers also manage payer enrollment, ensuring a provider’s organization can be reimbursed by insurance companies and government agencies (Medicare and Medicaid) for care patients receive. Each insurance company, or payer, has unique requirements that must be fulfilled exactly in order for providers to be recognized as in network. While the payer reviews the material submitted, effective credentialing specialists stay in constant communication, promptly addressing any additional information requests, ensuring a smooth and efficient enrollment process.

Why Is Experience So Important for Credentialing Professionals?

While many jobs can be learned in a classroom, healthcare credentialing is not one of them. Sure, you can learn the basics from a class or a mentor, but there are hundreds of unique situations that credentialers will find themselves in and on-the-job experience is the best way to know how to solve these challenges. Experienced credentialing professionals are adept at navigating challenges such as discrepancies in documentation or changes in regulatory requirements. Their expertise minimizes the risk of errors, which is essential in healthcare where mistakes can have serious implications for patient safety and the healthcare facility’s compliance with laws and accreditation standards. Their proficiency also contributes to the efficiency and reliability of the credentialing process, ultimately upholding the integrity and quality of healthcare services.

Examples of Valuable Credentialing Work Experience

Whether you’re an employer assessing candidates or an aspiring credentialing specialist, knowing the recipe for credentialing expertise is beneficial. While there are many examples of valuable work experience for credentialing professionals, there are a few background experiences that are especially useful to have.

Use of Credentialing Software: Proficiency in credentialing software demonstrates your ability to learn technology, set up (or follow) processes, and hopefully be motivated to automate aspects of the credentialing process.

Credentialing for Different Types of Healthcare Providers: Experience in credentialing diverse healthcare professionals, such as physicians, nurse practitioners, and therapists.

Management of Credentialing Databases: Uniform applications, portals, and databases (such as CAQH) are very common. Familiarity navigating technology and maintaining confidentiality is vital.

Communication with Medical Boards and Insurance Panels: Coordinating with various boards and panels for credential verification and compliance, with a proven track-record of good follow-up strategy.

Handling Recredentialing Processes: Managing the periodic recredentialing of providers to ensure uninterrupted payer enrollments and ongoing compliance with healthcare standards.

Navigating Regulatory Changes in Healthcare: Keeping up to date with changing regulations and standards in healthcare and adapting credentialing processes accordingly.

Expert Certifications: In addition to work experience, earning a credentialing certification demonstrates the expert’s knowledge and commitment to following regulatory guidelines in the credentialing process.

Technology and Tools Credentialers Should Know

Proficiency with certain technology and tools, such as credentialing software, databases, and document management systems, is key for credentialing experts. Familiarity with the technology and tools below assist credentialing professionals in navigating the process with confidence.

Credentialing Software: Systems like MedTrainer streamline the verification process and help to manage large volumes of provider data. Automation capabilities for routine tasks also reduce manual errors and save time.

Digital Verification Tools: Automated tools help to facilitate background checks and exclusions monitoring, allowing credentialers to efficiently verify credentials and compliance online.

Centralized Reporting Systems: Knowing how to efficiently gather data, store information, and run reports for status updates and compliance checks enables credentialers to quickly accurately assess each provider’s status.

Secure Document Sharing Platforms: A credentialer needs to know how to navigate document sharing platforms, such as PAVE or state licensing portals. These online hubs facilitate easy access to documents for authorized personnel.

Digital Provider Document Storage: Credentialers use digital repositories like MedTrainer’s provider profiles for quick access to provider information, verification, and enrollment status updates, with features like streamlined CAQH Provider Profile management that reduce duplicate data entry.

Electronic Health Records (EHR) Systems: Credentialers also know how to navigate EHR systems and interface with patient records and provider information, while abiding to HIPAA regulations. The expert accesses the EHT to ensure that healthcare providers’ credentials align with patient care requirements.

Credentialing Experience Employers Should Look For in Candidates Before Hiring

When hiring credentialing professionals, employers should prioritize candidates who have a comprehensive understanding of the credentialing process. This includes experience in verifying the qualifications of healthcare providers, managing documentation, ensuring compliance with healthcare standards and regulations, and proven processes for payer follow-up. A solid background in handling various types of credentials, such as licenses, certifications, and education verification, is also highly valued.

Employers should also look for candidates with a track record of maintaining up-to-date provider records and plenty of experience using credentialing software. Experience in navigating the complexities of payer enrollments and understanding the intricacies of healthcare regulations is crucial. Additionally, strong organizational and interpersonal skills, attention to detail, and the ability to work under pressure are key qualities to look for in a credentialing expert.

State of the Art Software That Credentialing Experts Love

Experienced credentialing professionals understand the value of a software specifically designed to reduce manual data entry, human error, and delays. Automated exclusions monitoring, customizable enrollment reports, and automated deadline reminders are just some of the features credentialing experts love about MedTrainer. Watch this short video to see how expert credentialers are streamlining tasks, increasing efficiency, and speeding up the credentialing process with MedTrainer.