Marina C. Jimenez, RDH, MHA
Director of Quality Assurance
The Herman Ostrow School of Dentistry
Credentialing is a systematic approach to the
collection and verification of providers
professional qualifications, such as:
•Relevant training
•Licensure
•Certification, and/or registration to practice in a
healthcare field
•Academic background
•Assessment of whether the practitioner meets
certain criteria relating to professional competence
and conduct
CLINICAL PRACTICE
COMMITTEE
QUALITY PROCESS
IMPROVEMENT
SUBCOMMITTEE
COMPLIANCE AND
CREDENTIALING
SUBCOMMITTEE
PROFESSIONAL
STANDARDS AND
POLICY
SUBCOMMITTEE
The Compliance and Credentialing Sub-Committee will, under the oversight of the CPC:
1) review and act upon all information received during the credentialing and re-credentialing process as defined by the School’s
policy for the granting, renewing, changing or terminating a practitioner’s clinical practice privileges;
2) oversee the implementation of the School’s compliance program developed as part of the University's Healthcare Compliance
Program.
Membership:
The membership of the Compliance and Credentialing Committee (CCC) is approved by the Dean and shall be comprised of
representatives from each of the clinical divisions and the Compliance Officer who shall constitute the voting membership.
Also represented on this committee in the status of ex-officio members are the Director of Faculty Affairs, Director of Quality
Assurance, Director of Healthcare Compliance; Director of Clinical Financial Services; Manager of Electronic Health
Records/axiUm and the Assistant Vice President of Healthcare Compliance for the University.
Additional faculty and campus representatives can be added as deemed necessary by the chairperson of this committee and as
approved by the Dean. Appointments shall represent a balance of clinical programs.
Terms will be two years or as otherwise determined by the Dean.
Meetings:
The Compliance and Credentialing Sub Committee will meet at minimum once a month. Additional meetings may be called by the
chairperson with at least 72 hours advanced notice.
Voting:
All faculty members of the Compliance and Credentialing sub-committee may vote. Non-faculty members are considered exofficio members and are non-voting members.
Quorum:
A majority of the voting members constitutes a quorum
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_______
Completed Application
_____ Current CA License (s) relative to job function (Primary Source Verification)
_____ Current CPR Certificate
_____ Current DEA Certificate (When Applicable)
_____ Curriculum Vitae
_____ Health Screening for TB / Hepatitis
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_____ On-line Compliance Education
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______ HIPAA Certificate
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______ OIG Exclusionary Check
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______ Signature Verification Form
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______ National Practitioner's Database Check
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______ Primary Source Verification of Work Experience
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______ Compliance Member in Good Standing Memo
‘Access’ database maintains all Human Resource
information
 Houses: Personal information, clinical status (i.e., patient
care, pre clinical), all licensures and certifications relative
to job function, credentialing dates, date of hire
 Manages Email reminders to providers at 90, 60, 30 day
intervals regarding upcoming credential expiries or
EXPIRED (cc to appropriate personnel as well as QA
office)
 Email notifications also sent when Personnel database
updates the provider profile relative to licensure and
certification (cc to appropriate personnel as well as QA
office)
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Under the direction of faculty, students
and residents enter treatment and
documentation relative to patient care in
the EHR
Faculty who oversee the student and
resident treatment ‘approve’
documentation by swiping their personal
axiUm ID card indicating approval
The axiUm ID card is tied directly to the
expiry set up in the axiUm user profile
Credentialing
Management
Maintains
regulatory
guidelines
Quality
delivery of
Care
Decreases
liability
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Effective credentialing policies and procedures
tied into the electronic health record (EHR),
demonstrates commitment to excellence in
delivery of quality care as well as compliance in
credentialing.
Modules within the EHR assist in managing and
provide support to ensure provider credentials
are current and valid in order to supervise care.
The benefits of the EHR do not stop at patient
care.
marina@usc.edu