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Buyer’s Guide Credentialing and Network Monitoring Software
5 Essential Steps for Choosing the Right Solution
Credentialing has long been a very manual process that is quick to be outsourced, but more network leaders are finding optimization opportunities that play a significant role in their overall network operations strategy. Not only is credentialing your first step in establishing relationships with providers, its downstream impacts go all the way to patient experience and continuum of care. Errors in the credentialing process can easily lead to an out-of-network referral and cost your patients hundreds or thousands of dollars in unexpected charges.
Without boiling the ocean, or taking on a complete digital transformation, there are practical steps you can take to change your process and see real results, quickly.
What if?
We designed this guide to help get you there with 5 essential steps to choosing the right credentialing and monitoring solution for your organization.
Step 1
Understand the Current Landscape of Credentialing and Monitoring Solutions
Most credentialing and monitoring solutions fall into one of three categories:
Tech-first solutions use modern API technology to connect directly to primary sources, enabling speed, scale, and integration with core systems like your CRM. For health plans managing large provider networks, the key advantage is process ownership: your team controls turnaround times, audit documentation, and real-time visibility into network status.
Legacy-tech solutions are longstanding platforms often branded as all-in-one solutions. New functionality is typically added via acquisitions rather than native development, which means integration with modern systems like CRM is not always prioritized and configurability can be limited.
Services-first solutions rely on a team of outsourced staff who conduct credentialing and monitoring tasks manually and share results via spreadsheet or shared portal. This category includes credentials verification organizations, or CVOs, which are third-party organizations completing credentialing on behalf of health plans. Using a CVO satisfies primary source verification requirements for the functions they perform, but turnaround times and process visibility depend on the CVO's capacity, not your own. For health plans managing large or growing provider networks, outsourced CVO costs can reach seven figures annually.
Each solution category has its place depending on your operational needs, technical maturity, and resource allocation.
When evaluating credentialing software versus a CVO, the core question is who owns the process. A CVO runs it for you. Software puts it in your hands, with the speed, audit documentation, and real-time visibility that outsourced models cannot match at scale.
Verifiable offers both: a tech-first platform built for health plans that need NCQA-compliant workflows and delegation support, backed by an in-house team of NCQA-certified experts, as well as an NCQA-certified CVO to handle overflow. It's the combination that lets you insource, outsource, or do both.
Step 2
Consider Your Operational Needs Today and Future Goals
To find the right solution, audit where you are today and where you want your credentialing operations to be tomorrow.
Where is the greatest administrative burden in the credentialing process?
It’s common for manual workflows to cause administrative burden on both the provider as well as the operations team. When you look for the most problematic areas currently, these signal your greatest opportunity for optimization.
Who in the organization interacts with credentialing on a regular basis?
Ensuring these handoffs are seamless is a key factor in determining your needs for workflow automation.
Which systems does your team rely on today?
Understanding which systems your team relies on today can tell you which systems you will want your credentialing platform to integrate with. For many health plan organizations, the mission-critical system for all provider data to connect to is their CRM, such as Salesforce.
What do we want to glean from our provider data?
By asking yourself this question early, you can go into project scoping with a clear set of requirements upfront. Items like custom fields, pre-configured reports, or specialized data models may become part of your requirements—you will want to ensure these boxes are checked off early.
Are you managing delegated credentialing agreements -- or planning to?
Health plans operating under delegation take on oversight accountability for the accuracy and timeliness of credentialing performed on their behalf -- and the software you select needs to support it. Your operational audit should surface how the platform manages roster submissions, whether it generates the audit documentation payers require during oversight reviews, and whether it supports your re-credentialing cycle requirements. If delegation is part of your current or planned operations, surface it as a requirement early -- not during contract negotiations with a vendor.
Health plans with delegated networks receive provider rosters from external entities — IPAs, health systems, DSOs, leased networks — and remain accountable for the accuracy and compliance of that data regardless of who performed the credentialing. The operational burden is significant: rosters arrive in inconsistent formats, on varying schedules, and with data quality issues that require validation before they can be trusted downstream in claims, directories, and network adequacy reporting.
The right platform handles roster ingestion at scale — standardizing incoming files, enforcing validation rules, flagging errors before they propagate, and automatically triggering monitoring for newly ingested delegated providers. If delegation is part of your current or planned operations, it should be surfaced as a requirement early in any vendor evaluation — the gap between a platform that handles your credentialed providers and one that also manages your delegated network is significant.
Step 3
Develop your technical requirements
Define stakeholder “must-haves” ahead of time to help narrow your focus when it comes time to start vendor evaluations. Ensuring that technical requirements align with cost and time savings metrics will help build your business case for approval.
Step 4
6 Questions to Ask Vendors
While many credentialing and monitoring solutions may look similar on the surface, they are not created equal.
Here are 6 questions to ask vendors you choose to evaluate:
- What provider types can you support with primary source verifications and data models?
- Which primary source verifications are automated without any human intervention?
- How can the solution help maintain an up-to-date provider directory?
- What level of customization and configurability are available?
- What types of reporting is pre-configured and what can be generated on demand?
- What are the average turnaround times your customers experience?
Step 5
Build Your Business Case
After gathering requirements and evaluating solutions, it comes time to prove it’s a worthwhile investment to make that can achieve short-term and long-term wins. Measuring your potential return on investment should include this multidimensional approach.
Immediate savings from vendor switch
Evaluate your current vendor contracts to understand your spend today. Especially those utilizing outsourced staff services and CVOs, the cost for this can reach up to 7-figures pretty easily.
That was exactly the case for Humana Dental, who replaced their CVO to move all of their credentialing operations in-house with Verifiable. They not only eliminated that 7-figure line item from their budget, but gained control and visibility of their provider network.
First year savings from staff efficiency
Measuring savings gained through automation will depend on how you are leveraging delegation agreements, as well as the solutions being used today for credentialing and monitoring.
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Credentialing/Recredentialing
Your current process will determine long-term savings
Sample Business Case
Profile
Regional Health Plan with 500,000 members, conducting some credentialing and all monitoring in-house
Weekly Compensation Equivalent Saved
Annual Compensation Equivalent Saved
$332
$17,261
Credentialing Events Expected In-House in Next Year
Annual Compensation Equivalent Saved
2,667
$128,221
% Displaced by Verifiable
100%
First year Savings (Compensation Equivalent)
Savings Per Member Per Year (PMPY)
$145,482
$0.69
Ready to Start
Exploring Solutions?
With Verifiable + Salesforce you can take advantage of:
- Intelligent Provider Profiles & Collaboration: Centralize profile data & insights to increase provider productivity and patient access to care.
- Error-Free, Fast Credentialing: Automate practitioner and facility workflows & documents to accelerate credentialing turnaround times. Faster medical credentialing = better provider experiences and network growth.
- Real-Time Trusted Source Integrations: Verify directly from required and recommended primary sources to receive instant feedback on network health and compliance.
- Proactive Network Monitoring: Access audit-ready reports & actionable alerts to stay compliant, understand your provider network, and reduce regulatory risk.