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PD#: EM393956

Sequence#: VARIES

Replaces PD#:   



Organization Title:



Agency: VARIES

Installation: VARIES

Army Command: VARIES


Command Code: VARIES





Supervisory Certification: I certify that this is an accurate statement of the major duties and responsibilities of this position and its organizational relationships, and that the position is necessary to carry out Government functions for which I am responsible. This certification is made with the knowledge that this information is to be used for statutory purposes relating to appointment and payment of public funds, and that false or misleading statements may constitute violations of such statutes or their implementing regulations.


Supervisor Name: SAVAGE, NANCY L

Reviewed Date: 07/26/2017

Classification Review: This position has been classified/graded as required by Title 5, U.S. Code in conformance with standard published by the U.S. Office of Personnel Management or if no published standards apply directly, consistently with the most applicable published standards.



Reviewed Date: 03/09/2012


Cyber Workforce:

  • Primary Work Role: VARIES
  • Additional Work Role 1: VARIES
  • Additional Work Role 2: VARIES



FLSA Appeal: NO

Bus Code: VARIES


  • Mission Category: VARIES
  • Work Category: VARIES
  • Work Level: VARIES

Acquisition Position: NO

  • CAP:  
  • Career Category:  
  • Career Level:  

Functional Code:  

Interdisciplinary: NO

Supervisor Status: VARIES



Drug Test Required: VARIES  

Financial Management Certification:

Position Designation: VARIES

Position Sensitivity: VARIES

Security Access: VARIES

Emergency Essential:   

Requires Access to Firearms: VARIES

Personnel Reliability Position: VARIES

Information Assurance: VARIES

Influenza Vaccination:  

Financial Disclosure: VARIES

Financial Disclosure: NO  

Enterprise Position: VARIES


Competitive Area: VARIES

Competitive Level: VARIES

Career Program: VARIES

Career Ladder PD: YES

Target Grade/FPL:  

Career Pos 1: EM394843  GS-0303-06

Career Pos 2:    

Career Pos 3:    

Career Pos 4:   

Career Pos 5:    

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Administers assigned credentials review and clinical privileging portion of USA MEDDAC Fort Riley for all physician and non-physician health care practitioners who require individual clinical privileges. Credentials review and clinical privileging includes initial granting/renewal of clinical privileges, appointment/reappointment to the medical staff, augmentation/modification of clinical privileges, management of adverse privileging actions, management of the impaired health care provider program, and maintenance of all practitioner credentials files (PCFs).

1. Serves as an authority on the credentials review and clinical privileging process. Provides advice and regulatory guidance, verbally or in writing, to practitioners and USA MEDDAC Fort Riley staff regarding both routine and complex privileging matters. Establishes working relationship with all clinical services, Quality Management (QM)/Risk Management (RM) and legal staff in order to manage current and accurate credentials file that will serve the needs of both the practitioner and the institution. Maintains current knowledge of procedures for obtaining and releasing credentials-related data; serves as liaison between USA MEDDAC Fort Riley Credentials Office, other military facilities, US Army Reserve (USAR) and US Army National Guard (USANG), and the civilian community in regard to both obtaining and dispensing credentials information.

a. Evaluates practitioner requests for clinical privileges in accordance with (IAW) Army Regulations, Department of Defense (DOD) Directives, and The Joint Commission (TJC) standards as published in the Comprehensive Accreditation Manual for Hospitals. Establishes and maintains PCFs for Department of the Army/TJSAR/IMA/NAAD/TJSANG/contract and partnership health care practitioners providing patient care at USA MEDDAC Fort Riley, ensuring that information contained in PCF is complete and accurate. Initiates action to obtain any missing information and documents. Ensures that appropriate credentials exist, e.g., board certification, residency and/or fellowship training to support requested clinical privileges. Ensures that health care practitioners utilizing new techniques/procedures have the appropriate clinical privileges prior to performing these procedures. Conducts primary source verification of credentials contained in PCF verbally or in writing and/or through review of reference literature. Solicits information from primary sources and previous employers of privileged health care practitioners. Maintains liaison with educational institutions and state licensing agencies throughout the United States, civilian and military hospitals in the U.S. and overseas, professional associations, specialty boards and appropriate staff offices of the U.S. Army Medical Command, and Education Council of Foreign Medical Graduates. Reviews responses received from requests for primary source verification of credentials and past experience and initiates appropriate action in response to receipt of adverse information. Initiates and processes queries to the National Practitioner Data Bank (NPDB). Manages IMPAC credit card. Maintains a current document register of funds expended by usage of IMPAC credit card for prime source verification of practitioner information and queries to the NPDB.

b. Completes pre-credentialing packets and reappointment documents by all physician and non-physician health care providers. Manages the appointment/reappointment process to ensure timely and appropriate privileges are maintained in support of worldwide deployability for both active duty and USAR providers. Assures that only personnel designated by the Deputy Commander for Clinical Services (DCCS) have access to credentials files and that no material is inserted or removed without approval by the Commander, Chairman of the Credentials Committee or DCCS.

c. Works as an integral part of the Quality Assurance process. Notifies the Credentials Committee concerning the individual's Provider Activity File (PAF) by computing statistical trend analysis to document QAJRM/UM/Blood and Drug Usage/Infection Control studies. Uses a thorough understanding of the Composite Health Care System (CHCS) and Centralized Credentials Quality Assurance System (CCQAS) data base management systems, individual data element fields and how these elements may be combined and presented in a meaningful, concise format.

d. Following notification of adverse events/information, analyzes the event/information taking into full consideration factors such as the impact to the patients, liability for the hospital, and evidence available. Advises Medical Treatment Facility (MTF) staff on adverse privileging action(s) by providing recommendations such as limiting, suspending, or revoking clinical privileges, initiating the process for adverse privileging actions and ensuring that proper procedure(s) are followed in all cases including appropriate notification of interested individuals such as the involved practitioner, department services chiefs, legal personnel, and higher headquarters such as U.S. Army Medical Command (MEDCOM); scheduling and recording of hearing committees, and submitting of all appropriate reports such as minutes of the Credentials Committee meetings, evidence, statements and documentation to higher headquarters. Coordinates with legal counsel to ensure that adverse privileging actions are managed appropriately and applicable regulations are followed. Monitors the action until higher headquarters makes final decision.

e. Reviews and updates local policies on credentials review and clinical privileging, a necessary. Reviews all forms utilized in the credentials review and clinical privileging process and revises as necessary or creates new forms to ensure compliance with regulatory guidance.

f. Researches and reviews literature relating to credentials review and clinical privileging in order to keep abreast of trends, governing regulations and directives, and requirements for obtaining/maintaining appropriate credentials, i.e., state licensure and certification in basic life support. Prepares summaries of significant information and distributes to the appropriate MTF staff. Collects, compiles, and maintains references and data in relation to credentials review and clinical privileges.

g. Educates all levels of MTF staff in matters concerning credentials review and clinical privileging to include general orientation to the process and requirements, introduction of new or revised policies relating the credentials review and clinical privileging process, and status reporting of ongoing credentials and clinical privileging activities.

h. Processes and maintains Remunerative Professional Civilian Employment (off-duty-moonlighting), Program for USA MEDDAC, Fort Riley. Ensures that privileged practitioners requesting off-duty employment are in compliance with appropriate directives (Interim Change No 10 1 to AR 40- 1, HSC Reg 600-3 and DOD Directive 6025.7).


2. Serves as Co-Action Officer and recorder for the Credentials Committee by preparing PCFs for presentation, preparing agenda and voting records, coordinating review of risk management cases referred from the Risk Management Committee, briefing Chairman on agenda items, advising Chairman and committee members on regulatory requirements, preparing minutes, and obtaining appropriate signatures on privileging documents following the meeting (NOTE: Timeliness is critical as newly assigned health care practitioners are not allowed to provide patient care until clinical privileges have been granted by the Commander as evidenced by his signature on the appropriate form.)

3. Serves as custodian of assigned PCFs, maintaining the security, integrity and confidentiality of all credentials and privileging information contained in PCFs and minutes of committee meetings. Maintains current knowledge of procedures for obtaining and releasing credentials and privileging related data. Establishes and maintains office files for credentialing. Duplicates, collates, and distributes correspondence, memoranda, reports, and minutes IAW applicable guidance. Provides privileging data for surveys and inspections. Ensures appropriate records are kept in a format that is acceptable to external review agencies that accurately and completely reflect the MTF privileging activities.

4. Utilizes personal computer, word processing, electronic mail, Photo PC 700, and CHCS/CCQAS data base software in order to provide office automation support. A qualified typist is required.

a. Input to and maintains CHCS/CCQAS databases in support of the credentialing and privileging function to effectively and efficiently manage information for all individually privileged health care providers at USA MEDDAC Fort Riley. Knowledge of an alphanumeric keyboard, computer files, fields and coding procedures to convert information from forms or reports to computer records. Extracts information from CHCS/CCQAS databases to initiate requests for renewal of privileges, update expired credentials, request missing information, etc. Makes recommendations regarding database revisions.

b. Maintains a current practitioner directory for USA MEDDAC Fort Riley. Utilizing digital camera, initiates/takes photo of practitioner upon arrival to USA MEDDAC Fort Riley and adds practitioner data to the hospital directory. Updated practitioner directory is published at least once per year.

c. Types and proofs correspondence, memoranda, reports and minutes. Knowledge of medical and quality assurance/risk management terminology to prepare official documents in final formats.


5. Maintains nursing personnel licensures and certifications. Ensures that all Registered Nurses and Licensed Practical Nurses, medics, OR technicians, etc., maintain current licensure, appropriate certification (if applicable) and CPR/PALS/NRP certification (as appropriate). Notification to appropriate personnel of upcoming expirations of required licensures and certifications.

Performs other duties as assigned.


A practical knowledge of the clinical practice of medicine to properly and fully implement the credentials review and clinical privileging portion of the USA MEDDAC Ft Riley Credentials Program for all physician and non-physician health care practitioners.

An extensive knowledge of and ability to interpret all TJC accreditation requirements, DOD directives, service specific credentialing related regulations, other related laws and regulations, and local policies and procedures.

A knowledge of and ability to apply data gathering methods, standardized processes and procedures, and identify and solve credentialing issues.

Ability to communicate effectively with various level of personnel throughout the organization and with regulatory agencies relative to requirements for accreditation and privileging.

Knowledge of automation and its use in data management and presentation.


Works under the general supervision of the Chief, Department of Quality Managent/DCHS and DCCS. The incumbent having expertise in the line of work independently is responsible for planning and carrying out the assignment, resolving most of the conflicts that arise, in accordance with regulatory guidance and accreditation guidelines; using discretion and judgment to determine appropriate methodology.

Performance is evaluated for quality and timeliness of service rendered and adherence to program policies and objectives by review of reports/minutes and recommendations submitted feedback from committees, and comments from external review sources.


Guidelines in the form of national legislation, DOD and service specific directives, JCAHO standards, health care law, licensing regulations, MEDCOM, and other external agency guidance are numerous, complex and have significant impact upon practitioner credentialing and privileging and ultimately institutional performance. Guidelines require interpretation and, in some cases, adaptation for application to problems or situations studied. In coordination with other organizations, incumbent reviews guidelines and develops recommendations for changes of program requirements.


Incumbent provides educational and consulting services to all physician and non-physician health care practitioners regarding credentialing and privileging process requirements and changes in standards set by regulatory agencies. Reviews all credentialing and privileging requests for compliance; verifies all documents and clears all discrepancies with originating institutions. Monitors, analyzes, and makes recommendations based on compliance of credentials review and clinical privileging process regulations, individual qualifications, and hospital equipment available.


Incumbent applies accepted principles, methods and guidelines to insure compliance and provide guidance in all matters concerning credentials review and clinical privileging processes. The functions, interpretations, and recommendations affect the accreditation of the hospital and the professional practices of licensed health care physicians.


Contacts are with all levels of hospital staff, external agencies such as Madigan Army Medical Center, Western Region Medical Command, U.S. Army Medical Command, American Hospital Association and The Joint Commission, as well as health care providers from other DOD medical facilities, Veterans Administration Facilities, civilian community and foreign country institutions and facilities. Contacts are for the purpose of researching, receiving and disseminating information relative to all functions of the credentials review and clinical privileging, interpreting policies and validating compliance with standards and regulations.


The work requires no special physical demands. It may involve some walking, standing, bending, or carrying of light items.


The work is performed in an office or similar setting requiring normal safety precautions against everyday risks or discomforts.

Fair Labor Standards Act (FLSA) Determination = (NON EXEMPT)


1. Availability Pay Exemption - (e.g., Criminal Investigators, U.S. Customs and Border Protection pilots who are also Law Enforcement Officers).


2. Foreign Exemption - (Note: Puerto Rico and certain other locations do not qualify for this exemption – See 5 CFR 551.104 for a list of Nonexempt areas.)


3. Executive Exemption:


a. Exercises appropriate management responsibility (primary duty) over a recognized organizational unit with a continuing function, AND


b. Customarily and regularly directs 2 or more employees, AND


c. Has the authority to make or recommend hiring, firing, or other status-change decisions, when such recommendations have particular weight.


4. Professional Exemption:


a. Professional work (primary duty)


b. Learned Professional, (See 5 CFR, 551.208 ) (Registered Nurses, Dental Hygienists, Physician’s Assistants, Medical Technologists, Teachers, Attorneys, Physicians, Dentists, Podiatrists, Optometrists, Engineers, Architects, and Accountants at the independent level as just some of the typical examples of exempt professionals). Or


c. Creative Professional, (See 5 CFR, 551.209 ) (The primary duty requires invention and originality in a recognized artistic field (music, writing, etc.) and does not typically include newspapers or other media or work subject to control by the organization are just some examples of Creative Professionals). Or


d. Computer Employee, (See 5 CFR, 551.210 ) ( must meet salary test and perform such duties as system analysis, program/system design, or program/system testing, documentation, and modification). Computer manufacture or repair is excluded (non-exempt work).


5. Administrative Exemption:


a. Primary duty consistent with 5 CFR 551 (e.g.; non-manual work directly related to the management or general business operations of the employer or its customers), AND job duties require exercise of discretion & independent judgment.

  FLSA Conclusion:
  Non Exempt

FLSA Comments/Explanations:

Not Listed


A qualified typist is required.



Grade Determination:

The standard applicable for grade evaluation criteria of this job is the Grade Level Guide for Clerical and Assistance Work. This guide evaluates the grade in two categories: Nature of Assignment and Level of Responsibility.

Nature of Assignment:

Work assignments involve a wide variety of problems or situations common to the segment of the program or function for which the employee is responsible as a Credentials Coordinator. Plans, develops, evaluates and coordinates all actions related to the Department of Quality Managent/DCHS and DCCS

Level of Responsibility:

Guidelines for the work encounter a wide variety of problems and situations which require choosing alternative responses. Employee must use significant judgment and interpretation to apply the guides to specific cases and adapt or improvise procedures to accommodate unusual or one-of- a- kind situations involved in use of the different programs.

The work most closely resembles that of a GS-07 according to the GLG.

Title Determination:

Since the GS-0303 series gives many options for titling, the best title for this job based on the purpose and major duties is Credentials Coordinator.

Final Classification: Credentials Coordinator (OA), GS-0303-7.