To understand the credentialing specialist role, first, you need to understand dental credentialing. The dental provider and the insurer enter into a contract that provides the best patient care with a continuous collectible rate.
The credentialing specialist ensures that the provider and the healthcare facility, like hospitals, Medicare, commercial payers, surgery centers, and Medicaid, comply. Credential specialists maintain all records related to staff credentials and insurance companies.
Ensure that all the necessary documents are there in the claim. That is where dedicated specialists come into play. They inform the dental practice staff and the insurer about the changes in the contracts and the policies. A benefit is that they are familiar with programs like word processing, spreadsheet, etc., as most of their work gets done through computers.
- High school diploma or GED in health information management
- Associate’s degree (bachelor’s/master’s) as per U.S. Bureau of Labor Statistics in health information management
- Credentialing specialists maintain each provider’s files with all the essential information required by the government and payer applications.
- They update the CAQH database file for the individual provider as per the compliance by CMS.
- Ensure the logins and other necessary information is accurate and maintained in the internal provider’s grid.
- Renew the provider’s license, such as DEA, Controlled Substance, or Professional, annually.
- Add dental providers while completing the credentialing applications to the Medicare, Medicaid, and commercial payers.
- For commercial payers, complete the re-credentialing applications.
- Ensure that the revalidation requests issued by the government payers get completed.
- Work with the billing staff and revenue cycle director to identify and resolve the denials. Complete the authorization issues related to the dental provider credentialing.
- Take care of credentialing the new provider and re-credentialing the existing providers.
- Update the provider’s profile on NPPES, CAQH, PECOS, and CMS.
- Optional certification from the National Association of Medical Staff Services.
- CPCS certification program for medical service professionals with a minimum of one year of experience.
- Preferred two years of credentialing experience.
- Two years of experience in the medical office role is preferred.
Abilities, Knowledge, and Skills
- Excellent computer skills, including word, excel, and the internet, as most of the work gets done on the computer.
- Knowledge of dental credentialing as the dental practice’s revenue cycle is dependent on it.
- It gets easier if the specialist is above average in organizational skills.
- Ability to meet deadlines with efficiency.
- Excellent communication skills.
- Looking forward to delighting customers.
The National Committee of Quality Assurance (NCQA) provides guidelines, including documentation and provider credentials. It is mandatory to apply NCQA standards. Later, in the field, you may pursue the Certified Provider Credentialing Specialist professional designation from the National Association of Medical Staff Services after three years of experience.
Why is dental credentialing vital?
- If the submitted claim does not have the provider’s details can lead to dental claims sitting for a time, disrupting the cash flow.
- It gets even more complicated when the patient is under the impression that the provider is in-network, and that isn’t the case.
- Dental credentialing is a long and complex process that requires a focused approach and reduces time if done correctly.
- For multiple providers, credentialing gets done separately. For multiple locations, this process is done separately for each dental office location.