GOAL:

To create a credentialing system for a health care organization that:

• Establishes the minimum requirements for provider status

• Facilitates the regular and objective evaluation of provider performance

• Meets requirements for accreditation by JCAHO and other organizations such as NCQA

WHEN NEEDED:

QMCG Credentialing System Design is appropriate to develop or redesign standards and systems for credentialing and re-credentialing providers in a health care organization in a way that will give the organization a competitive advantage while measuring quality.

DESCRIPTION:

QMCG Credentialing System Design Service assists the organization in the design of a credentialing and re-credentialing process that will satisfy the evolving requirements of the organization's market and the development and implementation of a plan. Flexible components may include:

• Credentialing committee development or redesign

• Initial credentialing process design or redesign

• Re-credentialing process design or redesign

• Privilege delineation criteria development

• Process for the structured onsite review of primary care practice sites (when indicated)

• Organization performance improvement processes (i.e. hospitals, surgi-centers, home health agencies, etc.)

• Provider profile of member satisfaction, quality and utilization data, etc.

• Privilege reduction, suspension or termination procedures and policies

• Appeals process

• Data requirements summary

• Plan for implementation

DURATION:

The design and implementation of the Credentialing System Design process can be accomplished in 3 to 5 months depending upon the needs and time frames established by the committee members.