The Basics

This standard requires that the organization designated at least one senior clinical staff person to perform the functions described in Core 11.  This standard sets forth at the required qualifications of that person.  Those qualifications are:

• a current unrestricted clinical license,
• sufficient qualifications (e.g., experience, credentials, certifications) to conduct clinical oversight for the services provided by the organization,
• post-graduate patient care experience, and
• if the person is an M.D. or D.O., board certification.

This person typically is the medical or clinical director of your organization.  In a PBM, the general expectation is that he/she is an M.D.  or a D.O.

Management Tips

People in management positions should keep in mind that it is not sufficient that your senior clinician meet these minimum requirements.  Rather, it is also required that the job description for that person, or some other document describing the person's role, require all of these qualifications.

The person occupying this position can be part time or full time.

URAC Accreditation Tips

All of the elements of this standard except the requirement for board certification are mandatory.  The board certification requirement carries the weight of three.

Documentation for the initial submission should include the designated senior clinician's job description and resume.  In addition, you should submit either a program description or policies and procedures that described the senior clinician's role and accountabilities.

The on-site review will hinge on an interview of the designated senior clinician.  In addition, the reviewer will examine the clinician's personnel file to assure that licensure, board certification, and work history are all documented appropriately.