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How to Become a Certified Medical Credentialing Specialist

Oct 20, 2021

What is credentialing? Learn what this career is all about, including the career steps for a medical credentialing specialist. Learn also the eligibility requirements for taking the medical credentialing exam and other certification requirements.

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Medical Credentialing Specialist preparing a medical bill for verification of physician

What is Credentialing in Medical Billing?

Credentialing in medical billing is an intensive process that involves background checks on physicians by the insurance companies to verify their education, whether they are legally authorized to practice medicine, and also their competencies. It is a way of checking that physicians have the required licenses, certificates, and other documents that are needed for one to practice as a healthcare provider. It is one of the essential parts of one becoming a trusted physician or a healthcare provider. A credentialed physician enters the insurer's network upon receiving credentialing certification and clients can refuse to join those not in the network.

Medical Credentialing Specialist

Medical credentialing specialists work in a variety of healthcare settings, including hospitals, ambulatory care facilities, insurance companies, and credential verification organizations. They typically perform activities associated with maintaining the credentials of medical providers within the organization. Duties may include updating files, assisting with the credentialing or re-credentialing process for members of the medical staff, verifying credentials, and completing clerical duties as needed.

Most medical credentialing specialists work on a full-time basis during business hours. They work in office settings within the healthcare field, spending little time on the move or on their feet. The risk of illness is small but present for those who work in proximity to sick patients.

Medical Credentialing Specialist Requirements

To get started in this career, a high school diploma is all that you need, but many employers prefer candidates with an associate's degree in healthcare or a related field. Medical credentialing specialists also need at least 12 consecutive months of experience prior to certification. Voluntary certification may increase job opportunities and offer job advancement.

Key skills that medical credentialing specialists need are

  • The ability to multi-task and work in a fast-paced environment
  • Strong written and verbal communication skills
  • Attention to detail
  • Analytical and research skills
  • The ability to work independently
  • Knowledge of the credentialing process and familiarity with medical terminology is helpful.

According to Payscale.com, in January 2021 credentialing specialists earned a median annual salary of $44,428.

How to Become a Medical Credentialing Specialist

What are the steps to becoming a certified medical credentialing specialist?

Step 1: Obtain a Degree

Although having a degree is not a prerequisite for becoming certified as a medical credentialing specialist, many employers look for candidates with at least an associate's degree. Some options include an associate's program in healthcare administration or health information. The benefit of completing a degree program includes gaining the advanced skills and knowledge necessary for a successful career in the healthcare field. Coursework commonly includes medical terminology, information technology, medical coding, and healthcare management.

Step 2: Gain Experience

After completing a degree program, gaining practical experience is a vital step to fulfilling the prerequisites for taking the certification exam. To be eligible to take the certification exam, an individual must have at least 12 consecutive months of experience working in a medical services environment. To gain an entry-level job, candidates usually need to have at least a high school diploma or GED. Employers increasingly prefer candidates with at least an associate's degree and/or some experience working in a related field, such as medical reception, billing, or staffing services.

Step 3: Determine Eligibility and Apply to Take the Exam

Eligible applicants for the Certified Provider Credentialing Specialist (CPCS) exam must either be a Certified Professional in Medical Services Management (CPMSM) in good standing and be employed for the past year in medical services, or be currently employed in medical services for at least a year with three years of experience within the past five years. To be eligible for the CPMSM exam, an individual must be a CPCS who has worked for the past year in medical services or has been employed for the past year in medical services with a total of five years of medical services experience within the past eight years. These requirements are applicable to anyone seeking to earn medical staff credentialing certification.

Individuals can access the application for either exam on the NAMSS website. It must be completed and mailed with the application fee to NAMSS. After the application is approved, applicants will receive a notice to schedule the exam appointment.

To improve your chances of success, schedule the exam appointment as soon as possible. Appointment times and locations are offered on a first-come, first-served basis. If the location and time that an individual wants is not available, another time and place must be chosen. NAMSS sends everyone a confirmation of the time and date for the exam within three business days of scheduling the exam appointment.

Additionally, you'll want to make sure that you prepare to take the exam. NAMSS offers a preparation course to get candidates ready for the exam. Preparatory courses are helpful to give individuals the knowledge and skills to successfully pass the exam and earn the certification. The prep course covers topics such as credentialing standards, regulation, credentialing application and approval processes, the privileging process, and potential licensing challenges.

Step 4: Take the Credentialing Certification Exam

To be admitted to the test, individuals must bring the confirmation email and photo identification to give to the testing proctor. The test is computer-based and includes a 15-minute tutorial to allow individuals to become familiar with the testing software. Test-takers have three hours to complete the CPCS test, which consists of 150 multiple-choice questions. Candidates for the CPMSM test have four hours to complete the CPMSM test, which has 175 multiple-choice questions.

To ensure success at this step, plan to arrive at the testing center at least ten minutes before the scheduled testing appointment. Anyone who arrives late may not be admitted to the test.

Step 5: Maintain NAMSS Certification

To maintain the certification, individuals must recertify with NAMSS every three years. For a single certification, individuals must complete 30 hours of continuing physician credentialing education. Individuals with a dual certification must complete 45 hours of continuing education. At times to understand how to get credentialing certification, one might have to attend medical credentialing classes to get acquainted with the whole process.

Step 6: Advance Your Career

Medical credentialing specialists with enough experience may be eligible for promotion into supervisory or management positions at their respective medical facilities. A bachelor's degree and certification can help a credentialing specialist qualify for management positions.

The understanding of these steps can guide one on how to credential a doctor with insurance companies or how to do credentialing for doctors. Credentialing health care professionals is a business by itself. One may however need to do some deeper research on how to start a credentialing business before embarking on such a venture. A credentialed physician may hire a benefit verification specialist who will be helping in collecting information from the insurance companies within their networks to check the benefits that the patients are entitled to. This ensures that the patients get quality service from both the doctors and the insurance companies because of the collaboration and coordination between them in service delivery.

To recap, with a high school diploma, at least one year of experience, and certification, you can become a certified medical credentialing specialist, which allows you to work in a variety of health care settings, updating files and assisting with the credentialing or re-credentialing processes.

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