A woman with curly hair smiles at a staff member sitting across the table.

Credentialing Non-Physician Staff Members

Don't get caught off-guard dealing with false identity or false credentials. Make sure you know and can prove that your medical team is who he/she says they are and are properly trained, licensed and certified to provide safe, competent care on behalf of your practice.

Posted in Risk Management on Tuesday, November 16, 2021

Acquiring employees with good clinical and/or administrative skills benefits your patients and your practice. Make sure you know and can prove that your medical staff is who they say they are, meaning they are properly trained, licensed and certified to provide safe, competent care on behalf of your practice.

Required Documents

During the hiring process, have potential employees sign a release of information form and advise him/her you will be looking into their education, training, licensure and certifications. Ask the candidate to provide:

  1. A current resume
  2. Copies of current licenses and certifications
  3. A copy of government issued photo ID

Primary Source Verifications (PSV)

Advise the candidate you will be conducting primary source verifications, or PSV, (i.e. IL Department of Professional Regulations for nurses practicing in IL, American Medical Association of Medical Assistants for Certified Medical Assistants, etc.) and will be performing sanction checks through the OIG Exclusions Database.

Additional Steps

  • Additional credentialing steps you may want to take before hiring a candidate include:
  • Performing a criminal background check
  • If applicable, ask candidates to request a report from the National Practitioner Data Bank
  • Have candidates request and present loss runs from prior insurance carriers

Annual Credentialing

Remember, credentialing does not stop once an individual has been hired. Annually, your credentialing review process should include:

  • Performance evaluations and, if necessary, an update of job descriptions
  • Documentation for continued training such as OSHA Compliance, HIPAA Compliance and other required training necessary for your office consistent with federal and state regulations
  • Confirmation of completion of continuing education to maintain licenses/certifications
  • Renewal of licenses/certifications
  • Confirmation of any professional liability insurance the individual is carrying. 
  • Additionally, NPDB queries should be generated for all clinical staff.  Queries should be run every 3 years.

Immediate Updates

Also, as licenses and/or certifications are renewed, update personnel records accordingly. This process above should be repeated with each license/certification renewal, not just at the end of the year.

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