A Day in the Life of a Medical Staff Credentialing Professional

A Day in the Life of a Medical Staff Credentialing Professional

Nov 2, 2021

Author: Noelle Abarelli, Contributing Writer, VerityStream

 

Medical Staff Credentialing Professionals have a myriad of responsibilities, from processing applications and verifying credentials, to managing clinical privileging, overseeing the approval process, and ensuring continuous performance improvement. As this is a profession that is consistently growing, we thought it would be beneficial to review a day in the life of a Medical Staff Credentialing Professional. Let’s dive in!

 

Who do Medical Staff Credentialing Professionals work with?

 

Here at VerityStream, we work with Medical Staff Credentialing Professionals representing different organizations, including hospitals, Credential Verification Organizations (CVOs), and Managed Care Organizations (MCOs). Each professional manages varying credentialing requirements depending on the type of organization they work for.


HOSPITAL

CVO

MCO

A hospital’s operational structure depends on its size as well as the type of hospital it is, like a pediatric hospital versus one that provides acute care.

 

Generally speaking, credentialing in hospitals is impacted by a variety of factors, including:

  • Federal and state laws
  • Different accreditation standards
  • Hospital and medical staff bylaws, rules, regulations, and policies
  • Standard of care, i.e.: what a reasonable organization would do in certain circumstances

The credentialing process for a CVO is influenced by its contracts, policies, and procedures; federal and state laws; and regulations and accreditation standards.

 

The most common accrediting bodies governing CVOs are:

MCO is an industry term used to collectively describe commercial third-party payers, healthcare networks, and health plans.

 

Their credentialing processes are influenced by:

  • Accreditation standards
  • Standards of care
  • Federal and state laws

What do Medical Staff Credentialing Professionals do?


Regardless of the type of organization that a Medical Staff Credentialing Professional works for, they have several key responsibilities. Their big, general focus is on processing applications and verifying credentials.


  • When it comes to credentialing and privileging, they are responsible for analyzing initial and reappointment applications, including all supporting documents for completeness in accordance with accreditation and regulatory standards.
  • They are also required to inform each practitioner of their application status, including the need to submit any additional information as applicable within specified timeframes.
  • When it comes to Primary Source Verification, they have to recognize, investigate, and validate discrepancies and adverse information obtained from the application, primary source verifications, or other sources. This is to ensure that the review and approval bodies have the information needed to make informed credentialing decisions regarding privileges or membership.
  • Medical Staff Credentialing Professionals have to obtain and evaluate information from primary sources to ensure compliance with accreditation and regulatory standards in order to validate the accuracy of applications for one or more decision-making bodies.
  • They must also verify and document expirables using acceptable verification sources to ensure compliance with regulatory standards.

After the application is complete, the department chair or medical director (depending on the organization: hospital, CVO, or MCO) reviews the application and makes a recommendation. It’s common for hospital staff to use a credentials committee for evaluations. This committee reviews the application and any supporting documents, along with the chairperson’s/medical director’s recommendation, and uses all that information to make their own recommendation to the medical executive committee (MEC).


In smaller hospital settings, or non-departmentalized hospitals, the application is usually presented directly to the MEC. The MEC then presents its final recommendation to the board, and the board makes the final decision. It’s important to note that though MCOs do not grant privileges, they do determine the applicant’s eligibility for membership/participation, and process requests for privileges to ensure compliance with regulatory standards.


How do Medical Staff Credentialing Professionals get it all done?


The work done by Medical Staff Credentialing Professionals can be complicated and time-consuming. When tasks require so much diligence, it’s helpful to have tools in place to help keep one organized and on-target. VerityStream solutions can simplify the process through automation. CredentialStream, for example, provides the most comprehensive provider lifecycle management solution available. With CredentialStream, Medical Staff Credentialing Professionals can use a single solution to manage initial and re-credentialing, enrollment, onboarding, expirables management, privileging, evaluation, network management, and much more. Request a demo today, and start improving patient care on your terms.

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