How To Become a Credentialing Specialist

Sarah Jones
Female professional working on laptop

Do you love details, organization, and the feeling of making a difference? Learning how to become a credentialing specialist might be the perfect path for you. 

It’s a career that blends administrative skills with healthcare, a role that maintains the integrity of quality patient care and upholds compliance. It is the credentialing specialist who guarantees that practitioners are qualified to provide the care patients trust them with. Read on to discover the steps on how to become a credentialing specialist.

What Is a Credentialing Specialist?

Credentialing specialists play a crucial role in the healthcare industry. They are responsible for collecting documentation and verifying the qualifications, licenses, and certifications of healthcare providers. This verification ensures that all providers, from doctors to therapists, meet stringent standards set by medical boards, hospitals, and other healthcare institutions.

After verifying provider credentials, the specialist then submits an application to each payer, or insurance company. This process is called payer enrollment and is required for a provider to be considered in-network. Each payer has different requirements, which means the specialist will have to pay special attention to detail to ensure there are no gaps on the applications. 

Credentialing specialists are also diligent with follow-up. Payer applications can take months to process. A proactive credentialing specialist will consistently contact the payers to check on the status of applications and keep the process moving forward. A credentialing specialist needs to identify any missing information the payer needs, collect the information from the provider, and then relay it the payer without delay.

What Education Is Required To Become a Credentialing Specialist?

A bachelor’s degree is typically the starting point for this career, often in healthcare administration, business, or a related field. And while a bachelor’s degree is often preferred, some employers accept an associate’s degree and/or relevant work experience in a healthcare or administrative role.

Hot Tip: Know what employers look for and use this checklist to prepare for your future interview!

If an academic path is pursued, prospective credentialing specialists benefit from courses in medical terminology, healthcare management, and health information systems. These subjects help to build a foundation of knowledge essential to understanding the intricacies of the role.

In addition to formal education, practical experience and on-the-job training are invaluable. Opportunities found in certification programs, such as those offered by the National Association Medical Staff Services (NAMSS), can further enhance a credentialing specialist’s qualifications and credibility in the field. These certifications, though optional, can significantly bolster career prospects.

How Long Does It Take To Become a Credentialing Specialist?

Becoming a credentialing specialist is not a one-size-fits-all journey. If one starts with a bachelor’s degree in a relevant field, it generally takes about four years. After completing the degree, gaining practical experience is the next step. Some employers may prioritize candidates with at least two years of experience in a healthcare setting. Therefore, a typical path could take around six years: four years for the degree and two years for hands-on experience. 

However, those who opt for an associate’s degree or have relevant work experience, might land a full-time credentialing position sooner rather than later. Ultimately, individual timelines vary based on personal choices, opportunities, and the specific requirements of potential employers.

Are There Any Certifications Required for a Credentialing Specialist?

Certification as a credentialing specialist is not always mandatory but is recommended. Holding a certification can significantly enhance a specialist’s marketability and professional credibility. The National Association Medical Staff Services (NAMSS) is a leading body that offers two principal certifications in this field:

Certified Provider Credentialing Specialist (CPCS)

Certified Medical Staff Coordinator (CMSC)

While these are examples of the two most popular credentialing certifications, there are other training and certification programs available. Choosing a certification path requires diligent research and vetting to find the best fit. Regardless of the certifying body an individual chooses, obtaining a certification can provide a competitive edge in job applications and career advancement; it may even be a prerequisite for certain positions or employers.

What Tools or Software Do Credentialing Specialists Commonly Use?

Technology plays a significant role in the daily tasks of a credentialing specialist. Familiarity with the following types of tools can give a credentialing candidate a boost in their career prospects:

Credentialing Software: These platforms streamline the verification process by housing all provider data in one location, and automate a myriad of processes from exclusion checks (OIG-LEIE and SAM) and reminder emails to schedulable reports and important deadline alerts.

Database Management Systems: For managing vast amounts of data related to healthcare providers, such as the CAQH database.

Electronic Health Record (EHR) Systems: These systems store patient data, and understanding them helps in relation to payer enrollments and claims reimbursement.

Communication Tools: Email, video conferencing, and instant messaging platforms facilitate communication with healthcare providers and institutions.

Document Management Systems: Organizing and managing provider documents can be difficult without an online document management system. With all information in one place, it’s easy to find without toggling between disparate systems.

Ultimately, a software solution that combines all these tools into one solution allows a credentialing specialist to work faster and more efficiently. By having everything housed and readily accessible in one location, standardized workflows can be established, fostering better compliance, consistency, communication, and collaboration. 


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Start Building Your Credentialing Specialist Resumé

Becoming a credentialing specialist is a dynamic journey that involves both education and experience. It’s a role that combines administrative tasks with the responsibility of ensuring quality healthcare. If you’re looking to embark on this path, you’ll need related education, hands-on experience, and possibly certification. Familiarize yourself with the essential tools and software to stand out. With dedication and persistence, you can absolutely build a rewarding career as a credentialing specialist.