Medical Staff Credentialing
Credentialing Medical Staff and Advanced Practice Professionals
Credentialing Process
Hunterdon Medical Center (HMC) is dedicated to pursuing the highest standard of quality care and patient safety by credentialing all licensed independent practitioners in compliance with The Joint Commission and other regulatory agencies.
Who needs to be credentialed and privileged at Hunterdon Medical Center?
- Doctor of Medicine (MD)
- Doctor of Osteopathy (DO)
- Doctor of Podiatric Medicine (DPM)
- Doctor of Medical Dentistry (DMD)
- Dentist (DDS)
- Advanced Nurse Practitioner (APN)
- Certified Registered Nurse Anesthetist (CRNA)
- Certified Nurse Midwife (CNM)
- Nurse Midwife (NM)
- Physician Assistant – Certified (PA-C)
- Registered Nurse First Assistant (RNFA)
- Surgical Assistant (Non-RN)
What is the difference between credentialing and privileging?
Credentialing is the primary source verification of a licensed independent practitioner’s education, training, claims history, work experience, licenses, etc. Privileging is granting approval for an individual to perform a specific procedure or specific set of procedures based on competence in the specialty in which privileges are requested. What is Primary Source Verification (PSV)? Primary Source Verification (PSV) is required for confirming that an individual possesses a valid license, certification or registration to practice a profession when required by law or regulations, and has relevant training and current competence. It is the responsibility of the accredited organization to complete PSV.
Processing Timeline
The Medical Staff Bylaws allow 180 days to process a complete application. The following represents a general timeframe for processing, based on the requirements outlined in the Bylaws and Credentials Manual. Please note that circumstances outside our control may impact processing days.
- Contact the Chief Medical Officer to determine if a request must be submitted to the Needs committee. If a request is required, it must be presented to the Needs Committee and approved by the HMC Board of Trustees (Exempt - Advanced Professional Practitioners, Contractors). (30 days)
- All hospital employees must complete an HR application and sign an employment contract.
- Once a request is approved by the HMC Board of Trustees, a Request for Application form is sent to the applicant to complete and return to the Medical Staff Office (Timeframe is dependent upon the applicant)
- When the Request for Application form is received, a link to an application is sent to the applicant by email (3 days)
- Once the request has been processed, you will receive two emails from mtorkelson@morriseyhosting.com containing Username and Password to log in to the portal to complete.
- Supporting Documents Required:
-
- Practitioner Photo (headshot – professional image)
- Curriculum Vitae (CV) – must include month and year (to and from dates)
- New Jersey Medical License
- New Jersey Controlled Substance License
- Malpractice Insurance Certificates for past 10 years
- DEA Registration
- CME Documentation, if applicable
- BLS, if applicable
- ACLS, if applicable
- PALS, if applicable
- Advanced Life Support Obstetrics, if applicable
- ECFMG Certificate, if applicable
- Flu Vaccine
- PPD Test, T-Spot Quantiferon Gold – from the last 12 months
- Immunizations – MMR
- COVID 1st, 2nd and Booster
- Claims Summary, if applicable
- Privilege (if not available online)
- Collaborative Agreement (NP’s only)
- Supervising Agreement (PA’s only)
- Case logs (per criteria on Privilege Form)
- Initial Application Fee
- There is an Initial Application fee of $750.00
- The application must be submitted within 30 days. Prior to submitting, the applicant must contact the Manager, Medical Staff Office, to review prior to submitting the application through the portal. ALL REQUESTED DOCUMENTS, INCLUDING NEW JERSEY STATE LICENSE, MUST BE UPLOADED. (30 days)
- Once the application is submitted, it is reviewed for completeness. (6 days)
- If any information is missing, the applicant is notified and requested to submit required information. (Timeframe is dependent upon the applicant)
Day 0 - Application submitted is COMPLETED and ready to process.
- Day 1-45 – Gather all primary source verifications, follow up as necessary.
- Elements that must be verified:
- Medical School, internship, residency and fellowship (Medical Staff)
- ECFMG (if applicable)
- Graduate Education (APPs)
- All past and current licenses, CDS, DEA, Board Certifications
- Malpractice Coverage for the past 10 years
- Past and current employment and hospital affiliations
- Three references – Must be one (1) Clinical Director - For APPs must be Collaborative or Supervising Physician; and two (2) Peer References – must be colleagues that can attest to the applicant’s clinical competency who have worked with the applicant in the past 12 months and have the same degree or higher
- Office of Inspector General (OIG)
- System for Award Management (SAM)
- Background Check
- National Practitioner Data Bank
- Gaps in education, employment, or hospital affiliations over 30 days
All items provided by the primary source verification are reviewed with the items provided with the application. If there are any discrepancies with the application and primary source verification, the provider will need to give an explanation of the discrepancies.
- Day 45-50 – Complete Internal File Audit
- Day 50–64:
- Division Director review and recommendation, if applicable
- Department Chair review and recommendation
- Chief Nursing Office review and recommendation, if applicable
- After Day 64:
- 4th Wednesday Monthly – APP Committee review and recommendation
- 1st Thursday Monthly – Selection & Credentials Committee review and recommendation
- 2nd Tuesday Monthly – Medical Executive Committee review and recommendation
- 2nd Wednesday/Thursday – Expedited Committee review and approval, if criteria are met (board letter sent to applicant)
- 3rd Thursday Monthly – Quality Safety Experience Committee review and recommendation
- 4th Thursday Monthly – Board of Trustee approval (board letter sent to applicant, if not approved at Expedited Committee)
- Orientation, NextGen and QCPR training (online form will be sent with available dates), Dictation ID/Password, Marketing/Photo, and Hospital ID Badge
- Provider Enrollment with Central Billing Office (employed only) and Hunterdon Healthcare Partners credentialing (if applicable)