Verification Procedures
Selection Process
Process for Verification of Qualifications, Licenses and Certifications
Procedures for Renewal of Qualifications, Licenses and Certifications

Aliron's Credentialing Process is a comprehensive process providing verification for the initial application as well as the application for recredentialing. The credentialing (review/verification) process has been developed for both efficiency and thoroughness.

Initial credentialing processes are on-going and must be up-to-date. The process entails PSV verification, written, or oral (if oral, a dated, scripted note in the Provider Credential File (PCF), stating who verified the item and how it was verified is required), of the following (as appropriate to/required for the position) from the primary sources:

• A current, valid state license to practice
• Clinical privileges in good standing
• A valid DEA certificate
• Board/other certification
• Residency certification
• Graduation from medical/other school
• A five-year work history, which must be included on the application
• Current, adequate malpractice insurance
• Professional Liability Claims History

Also:

• Clinical/peer references of the same discipline
• CME including certification in CPR/ACLS/BLS or other certification
• National Practitioner Data Bank/HIPDB Information

The recredentialing process is on-going, up-to-date, and occurs at least every two years. Criteria are similar to those of the original credentialing.

All credentialing activity follows a similar process and high level of standard for all categories of health care providers.

Purpose of the Credentialing Department

The purpose of the Credentialing Department is to present to the customer verified applicant credential files which are complete and lead to the approval of the applicant for employment in the identified position/contract.

Scope of the Credentialing Department

The scope of the Credentialing Department is to obtain and verify credentials of health care providers following the standards established by JCAHO and NCQA.

Primary responsibilities of the Credentialing Department include:

• Processing applicant file by obtaining primary source verification, either written or verbal, and appropriately formatting the completed Provider Credentials File for presentation to the customer in a timely manner.

• In achieving the above end, the C.D. conducts a comprehensive review/evaluation of the credentials cognizant of "Red Flags" - i.e., become aware/detect areas of concern/adverse information which may preclude the presentation and approval of the applicant file for acceptance by the customer.

"Red Flags" that may indicate problems in completing the credentials verification process for the identified applicant:

• Gaps/Missing Dates
• Frequent Moves
  • Training
  • Group Practice
  • Hospitals
• Discrepancies Between Information on Application & Response from Written/Verbal Verification
• Hospital Privileges, License, DEA: Suspended, Revoked, Reduced
• Malpractice Insurance Canceled/Excessive Claims
• Felony Conviction
• Reference Letters From:
  • Relative
  • An Individual Who Never Worked with the Applicant
• Data Makes No Reference to Skill, Performance
• Confirmation of Dates Only With No Reference to Skill, Performance

Personnel

The Credentialing Department staff shall be comprised of individuals experienced in the credentials verification process and procedures for health care providers and are committed to providing quality, comprehensive and timely services benefiting our customers.

Proposed Job Descriptions for:

• Credentials Department Manager
• Credentialing Coordinator

are included in this section.