Independent Review Organization: Internal Review 5.0

IR-INT 3 - Credential Status Changes

Submited by: Tom Goddard

The Basics

This standard requires that the IRO have and implement policies and procedures that both

  1. require the IRO's staff members to notify the IRO in the event there is an adverse change in the status of the staffer's license or certification (including board certification) and
  2. provide a procedure to implement a corrective action plan in the event of such an adverse change.

In other words, if a member of the IRO's staff should have licensure or certification either downgraded or pulled, the staffer must notify the IRO and the IRO must take prompt and appropriate action, such as re-assigning the staff member to an assignment that doesn't require licensure and/or certification.

Management Tips

As is the case with all policies and procedures, make sure that yours are sufficiently clear to guide all the involved staff members on each step in both the reporting process and the development and implementation of the corrective action plan. It will not suffice to describe what the organization will do; rather, your team members need to be able to follow the directions provided in the P&P.

Accreditation Tips

Desktop Review

All you will need to submit at the desktop review phase is the policy and procedure that addresses both elements of this standard. If you do have a form for the corrective action plan, submit that, too.

Validation Review

Document review

The reviewer will, as a part of the review of more than 30 files described in earlier standards, look for evidence of compliance or non-compliance with this standard. In other words, if the reviewer should find that a member of your staff that had a compromised license or certification worked on one or more of these files, the reviewer likely will find that the IRO has not complied with element (b) of this standard.


The URAC reviewer will interview a variety of staff members, including those in charge of selecting reviewers and verifying reviewer credentials.

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