Core 4.0 Pre-release

C-OPIN 3-1: Job Descriptions and Staff Qualifications

Submited by: Tom Goddard

The Basics

This standard requires that your organization hires qualified staff, and that the measure of staff's qualifications is, in part on the extent to which staff meet the qualifications required by written job descriptions. In other words, each position in the organization has a written job description, and each staff member meets the qualifications of the applicable job description.
Each such job description must set forth:

  • the scope of the position's responsibilities, duties, and roles;
  • any minimum requirements for experience, training, and/or education; 
  • any certification or licensing requirements; and
  • the staff member's expected competencies.
URAC has a broad definition of "Staff": "The Organization’s employees, including full-time employees, part-time employees, and consultants." So, make sure you include 1099 consultants along with your W-2 employees. The only difference for consultants is that it would be inappropriate to have a job description for a consultant. Instead, you should have a copy of the written contract that includes the above requirements (e.g., responsibilities, experience, licensing, competencies).

Management Tips

It is particularly important that every member of the staff meet the requirements of the description of the job he/she occupies at any given time. If you envision exceptions, such as the instance in which a company veteran with proven skills is hired into a position for which he/she doesn't meet the formal requirements, make sure your governing policy and procedure describes the process by which such an exception is made. For example, you may have a documented process by which the manager and HR director agree that, despite the failure to meet the formal requirements of the job description, the employee is qualified for the position. Documentation of that process is critical.
Another approach would be to modify the job description so that the requirements that the employee does not meet are listed among the "preferred" requirements, not "required".

Accreditation Tips

Desktop Review
Submit the following documents:

  • Policies and procedures requiring that
    • each member of the staff meets job description requirements and
    • the process for validating that each staff member meets those requirements
  • Template job descriptions for each position in the company
Validation Review
Document review
You'll need to provide the reviewer with a complete listing of all staff members, including employees, consultants, and temporary staff members. From that list, the reviewer will select a sampling of staff members and compare job descriptions to resumés or job applications to ensure compliance with the job descriptions' requirements.

  • Core 4.0 Pre-release / 12.31.2018

    C-RM 3-1: Information Systems Risk Assessment and Reduction

    URAC assumes that your organization has a comprehensive risk management program, and in this standard, requires that your information systems are a component of that system. Specifically, the IT component must address explicitly data storage, gathering, and transfer.Your organization must conduct risk assessment in these three areas, and that assessment must periodically include "an entity with th...

  • Core 4.0 Pre-release / 12.26.2018

    C-RM 2-3: Business Continuity Plan Testing

    Your organization must test its business continuity plan ("BCP") no less frequently than every two years. Notably, the BCP test can be a tabletop exercise, which URAC defines as:test of a Business Continuity Plan (BCP) that includes documentation of the following aspects of the test:A tabletop exercise simulates an incident in an informal, stress-free environment.The participants who are usually t...

  • Core 4.0 Pre-release / 12.26.2018

    C-RM 2-2: Pharmacy Emergency Management Plan

    Applicable only to organizations seeking accreditation in one of URAC's pharmacy modules, this standard requires that your business continuity plan describe an emergency management system that addresses how the organization will distribute medications in the event of an emergency. The description must address the organization's facilities, its services, and its products in some detail. As was the...