Credentialing is used by healthcare organizations and health plans to verify education, training, and experience of medical staff. When a physician or licensed independent practitioner (LIP) is credentialed they become affiliated with that organization and are members of the medical staff or health care network. The organization’s owner or governing board is held legally accountable for the quality of care and staff conduct and the medical staff is accountable to the governing board for the quality of care they provide. The credentialing process determines if medical staff is competent and capable to treat and care for patients before allowing membership or network affiliation.
The medical staff committee is in charge of conducting competency evaluations using established governing board criteria - character, competence, training, experience, and judgment. Competency evaluations are completed according to medical staff bylaws and include background checks, privilege delineation, and confirm level of competency. A competency evaluation is required for new applicants, reappointment (every 2 yrs.) and medical staff privilege change requests. New applicants present the organization with a formal application request for membership- active, courtesy, consulting or allied health. A request can be for membership only, core privileges, or catagorized privileges. Along with the application the following information is required: current licensure, DEA certificate, liability insurance, details on education, training, and experience, board certification/re-certification, medical society memberships, medical litigation – filed, pending, or settled, unfavorable peer reviews, felony conviction and voluntary or involuntary privilege reductions,...
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...ions allow for due process, “a formal proceeding conducted in a way to protect the rights of all involved” (p.143).
Managed care organizations (MCO) credentialing process follows National Committee on Quality Assurance (NCQA) standards which require verification of license, DEA certificate, education & training, board certification, liability claims, and work history. Primary source information is verified using the Universal Provider Datasource, NPDB is accessed, and site visits review and evaluate patient records. The MCO credentialing committee makes the decision to accept or reject new applications or reappointments. On-going PPEs follow NCQA standards requiring data collection and review of Medicare & Medicaid sanctions, licensure restrictions, complaints, and adverse events. A MCO is held legally accountable for hiring and retaining incompetent employees.
Michelle Blesi, Barbara A. Wise, R.N., Cathy Kelley-Arney, Medical Assisting: Administrative and Clinical Competencies, 7th edition (pp.54-58). Cengage Learning-Publisher
I now that I have the knowledge to aspire to take up my role within one of the identified population foci. APRNs program developed my core competencies by allowing me to be more efficient adaptability with regards to newly emerging APRN roles or population focus. Furthermore, achieving my course objectives enable me to understand the specific APRN roles. For example, course objectives provide me with a better detail, and align my licensure goals with the responsibilities expected of each role. Licensure will provide me and my fellow APRN graduates with the full authority to practice. Also, certification is required to meet the highest possible standards as APRNs are expected to align knowledge, skills and experience with the standards of health care professionals. This field has very narrow margins for error, and it is therefore important, for APRNs to meet the highest and most stringent academic qualifications. In order to be a recognized as APRN graduate, one is required to complete formal education with a graduate degree or post-graduate certificate awarded by an academic institute and accredited by a recognized accrediting agency empowered by the relevant government education
State and federal regulations, national accreditation standards, and clinical practice standards are created, and updated regularly. In addition, to these regulations, OIG publishes a compliance work plan annually that focuses on protecting the integrity of the program, and prevention of fraud and abuse. The Office of the Inspector General examines quality‐of‐care issues in nursing facilities, organizations, community‐based settings and occurrences in which the programs may have been billed for medically unnecessary services. The Office of the Inspector General’s work plan for the fiscal year 2011 highlights five areas of investigation for acute care hospitals. Reliability of hospital-reported quality measure data, hospital readmissions, hospital admissions with conditions
A certified medical biller is one who passes the Certified Medical Reimbursement Specialist Exam and because of the certification, they are greatly sought after. Medical billing presents the chance for a well-organized, task-oriented individual to use her eye for specificity in a crucial role within the health care industry. A biller with a good sense of self-concept can communicate effectively because they are confident in themselves, they can accurately rea...
I consider my care staff to be my patient care coordinators, treatment coordinators, and assistants. Doctor’s and Hygienists also need to be meet with to understand their philosophy and what I can do as a Manager to make there day run as smooth as possible. As a leader the staff needs to understand my philosophy, their expectations of other and what I would expect of them short and long term. Further 1:1 meetings in the following 30 days would be set up to further address after observation is completed.
The objective of the MCEG is to provide channels to exchange information between managed care/health plan information systems executives and to provide opportunity for personal networking. MCEG provides a forum to develop policy which relates to the use of information technology and healthcare. MCEG provides feedback to vendor sponsors and other vendors on the trends and types of technology needed to ensure that their products and strategies meet their customer’s present and future managed care needs. Additionally, their objective is to “educate executives on clinical and administrative trends in health care, new and emerging technologies, and other pertinent information to assist in achieving the key goals of cost containment, effective service and high quality health care.” (Why We Matter, 2011)
Licensed practical nurses (LPN 's) fill an important role in modern health care practices. Their primary job duty is to provide routine care, observe patients’ health, assist doctors and registered nurses, and communicate instructions to patients regarding medication, home-based care, and preventative lifestyle changes (Hill). A Licensed Practical Nurse has various of roles that they have to manage on a day to day basis, such as being an advocate for their patients, an educator, being a counselor, a consultant, researcher, collaborator, and even a manager depending on what kind of work exactly that you do and where. It is the nursing process and critical thinking that separate the LPN from the unlicensed assistive personnel. Judgments are based
Licensure grants the authority for the APRN to practice in the population foci (APRN, 2008). Accreditation is a formal review of a nursing program approved by a recognized nursing agency (APRN, 2008). Certification is a formal recognition of knowledge, skills and education that is demonstrated by set standards identified by profession (APRN, 2009) Lastly, education is the formal preparation of APRNs for graduate or post-graduate program (APRN,
According to Weis/Tappen (2010) competency is defined as “the demonstrated ability to carry out specific tasks or activities with reasonable skill and safety that adheres to the prevailing standard of practice in the nursing community” (p. 262). To be competent a person should be able to perform a set skill at an expected level. Pertaining to nursing, competence is shown by skill provided in healthcare with safety and understanding of how it is to be performed. The nurse is responsible for continuing competency throughout his/her career in order to meet the performance level set by the healthcare facility they are employed by.
The American Board of Nursing Specialties describes certification as the proper acknowledgment of specialized skills, knowledge, and practice demonstrated by the accomplishment of standards outlined by a nursing specialty. The certification associated with specialty practice regularly functions as a professional landmark. Validation by an outside source endorses that an individual has met the established national standards. When an advanced practice nurse prepares to become certified in his/her specialty there must be proper preparation in order to be successful.
The National Center for Competency testing, or NCCT, has been operating since 1989. They are an organization that test healthcare professionals and instructors to provide them with the correct credentialing for their field of work. They provide multiple qualifying paths for certification in medical assisting, medical office assisting, insurance and coding specialist, ECG technicians, Phlebotomy Technicians, patient care technicians, surgical technologists, and post secondary instructors. They have different exam prices for all the above professions and they are organized by different routes. .
The purpose of quality initiatives is to promote safe, timely, effective, efficient, equitable patient centered care( DeNisco & Barker, 2013). The quality improvement evaluation is important in the health care industry to find out the best practice care and to provide high quality cost effective care to patients. The public and private agencies are the regulatory entities in the health care Industry which promote quality and safety in the delivery of health care. The major regulatory agencies are CMS, the Joint commission, and AHRQ (deNisco & Barker, 2013).
...n of Healthcare Organizations (JCAHO), and the American Medical Accreditation Program (AMAP), just to name a couple. Each of the accrediting bodies is unique in terms of their mission, activities, compositions of their boards, and organizational histories, and each develops their own accreditation process and programs and sets their own accreditation standards. . "Accreditation of a health care facility or program is a symbol of quality, similar to the Good Housekeeping Seal of Approval that indicates to the public that the organization or program has met certain standards." (Goode, 2001) The accreditation proves that healthcare facility underwent the accreditation process and met all of the necessary requirements to become qualified. Accreditation has been generally viewed as a desirable process to establish standards and work toward achieving higher quality care.
Being reliable, respectful, and competent working as a medical professional understanding the job, and performing it at high standards. Medical professionals
...sfied with the outcome and resolution from the mediation session, the parties are given liberties to engage with a court procedure.