Credentialing Checklist - Medical Resource Staffing

1. Application

(Any deliberate inaccuracy on the application will result in an automatic denial)

Received
Reviewed
Approved
Denied

2. Resume

(Any red flags or false information on the resume will result in automatic denial)

Received
Reviewed
Approved
Denied

3. Interview

(Any red flags or false information on the interview will result in automatic denial)

Pending
Performed
Approved
Denied

4. Professional questionnaire

(If all answers to the questionnaire are NO, this section will be approved. Answers YES to questions 1, 2, 3, 7, 8, 9, 10, 12, 13, 14, 15 will be reviewed on a case by case basis. Answers YES to questions 4, 5, 6, 11 will result in an automatic denial).

Received
Reviewed
Approved
Denied

5. Professional references

(Minimum 3 referenced must be provided. If the applicant is three years within completion of training, one of the references must be program director. If all answers to questions are Satisfactory/outstanding, No to health status and applicant is recommend without reservation this portion will be approved. If any answers to questions are unsatisfactory and answer to health status is yes and there are reservations about the applicant; this will be reviewed on a case by case basis. Any references indicating “do not recommend the applicant” will result in automatic denial.)

Received
Reviewed
Approved
Denied

6. Claims history

(Claims history will be verified by MRS staff. Any history will be reviewed by the medical director and a case by case basis. Any court judgment against the provider will result in automatic denial)

Received
Reviewed
Approved
Denied

7. NPI number

Verified

8. Copy of educational certificate as applicable (Master of Science in Nursing (MSN), Doctor or Nursing Practice (DNP), Master in Physician Assistant Studies (MPAS), Medical School Diploma, Residency Certificate, Fellowship Certificate if applicable).

(MRS will verify accuracy).

Received
Reviewed
Approved
Denied

9. Training certificates as applicable (BLS, PALS, NRP, ACLS, ATLS, ALSO etc)

Received
Reviewed
Approved
Denied

10. Copy of medical license per state

(must be verified by MRS).

Received
Reviewed
Approved
Denied

11. Copy of controlled substance registration certificate if applicable

(must be verified by MRS).

Received
Reviewed
Approved
Denied

12. Copy of federal DEA registration

(must be verified by MRS).

Received
Reviewed
Approved
Denied

13. Consent, authorization for release of information and release of liability form must be signed by applicant

Received
Reviewed
Approved
Denied

14. Federal and state criminal background check

(any criminal history will result in automatic denial).

Performed
Approved
Denied

15. Sexual abuse registry

(Any sexual abuse history will result in automatic denial).

Performed
Approved
Denied

16. MRS must receive written confirmation in the form of email or letter from potential providers prior to presenting them to potential clients.

Pending
Received

17. Checklist will be reviewed by medical director:

Pending review
Reviewed

Application Status

Application approved
Application denied

Medical Director: Ahmed El-Emawy, MD

Signature

Date

Medical Resource Staffing LLC

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