Credentialing for RWJBarnabas Health Hospitals

Medical Professionals

Who needs to be credentialed?

Every physician must apply for privileges to be affiliated and attend to patients at a hospital. With that in mind, it doesn’t matter whether you are beginning your own private practice, joining an existing group practice, or becoming part of a hospitalist group – if you want to treat patients at a hospital, you need be credentialed.

What is the difference between Credentialing and Privileging?

Credentialing is the process used to evaluate your professional qualifications and establish whether you are clinically prepared to safely treat patients. Privileges refer to the specific medical procedures that you are granted permission to perform within the hospital. For example, an internal medicine physician may be credentialed at a hospital, but would not likely be granted privileges to perform orthopaedic surgery.

Why do I need to send all this information to become credentialed?

RWJBarnabas Health is dedicated to excellence in clinical care and ensuring patient safety. By collecting this information, RWJBarnabas Health makes certain that all physicians and other clinicians (NPs, PAs, APNs, etc) are in good standing, up-to-date with all state and federal licenses, and well-trained to safely treat patients in their specialty.

Additionally, the Joint Commission, which provides accreditation for RWJBarnabas Health hospitals, also dictates requirements that must be included within the Credentialing Application. The Joint Commission may at any time request documentation on a health care provider that a hospital must provide. So in addition to ensuring quality of patient care, it is also critically important for RWJBarnabas Health to maintain accurate, up-to-date records of each health care provider to respond to these types of inquiries to maintain the hospital’s accreditation.

Describe the Credentialing Process.

Step 1 – Request the Credentialing Application. Each hospital within the RWJBarnabas Health system has their own Credentialing Department. Please see below for comprehensive list of contacts.

Clara Maass Medical Center
Jodi Ombaldo Jodi.Ombaldo@rwjbh.org | 973-450-2015

Community Medical Center
Angela Clute Angela.Clute@rwjbh.org | 732-557-1516

Jersey City Medical Center –
Dorothy Shaw Dorothy.Shaw@rwjbh.org | 201-915-2505

Monmouth Medical Center
Heather Bamburak Heather.Bamburak@rwjbh.org | 732-923-6523

Monmouth Medical Center – Southern Campus
Susan Heck Susan.Heck@rwjbh.org | 732-886-4591

Newark Beth Israel Medical Center
Johanna Silvester Johanna.Silvester@rwjbh.org | 973-926-7384
Martha Diaz Martha.Diaz@rwjbh.org | 973-926-7013

RWJ University Hospital Hamilton -
Amy Koveleski Amy.Koveleski@rwjbh.org | 609-584-6415

RWJ University Hospital New Brunswick -
Nicole Berner Nicole.Berner@rwjbh.org | 732-937-8767

RWJ University Hospital Rahway -
Felicia Williamson Felicia.Williamson@rwjbh.org | 732-499-6070

RWJ University Hospital Somerset -
Melanie O'Donnell Melanie.ODonnell@rwjbh.org | 908-595-2646

Saint Barnabas Medical Center
Lori Hogge Lori.Hogge@rwjbh.org | 973-322-5059

Step 2 - Complete your Credentialing Application. We have included below a detailed checklist of the typical documents and waivers that you are required to submit within the credentialing application.

Step 3 – Upon submission of your completed application, the background information is primary source verified by a third-party credentialing company.

Step 4 – You will be asked to interview with your respective Department Chair.

Step 5 – Your application goes through Committee Approvals. This process may vary from hospital to hospital, but will likely include; Credentialing Committee, Medical Executive Committee and the Credentialing Subcommittee of the Board of Trustees. Ultimately, it is the Board of Trustees that appoints physicians to the medical staff.

Step 6 – Assuming all goes well – Your application to be credentialed will be approved and now able to practice in the hospital!

How much time does the Credentialing Process take?

Upon submission of a complete application, the credentialing process with RWJBarnabas Health hospitals typically takes about 8 weeks. However, the length of time required to complete the application may vary depending on program/department, number of years in practice, ease or difficulty in obtaining primary source verification (i.e. verify from the original sources listed on your application that you have successfully completed medical school, completed residency training, held other privileges, provided accurate information regarding malpractice history, and have an active state license, etc.) Later in your career, if you have worked at many institutions, the credentialing company would need to contact multiple hospitals to validate your experience. This process will take longer as compared to a resident who has recently completed his/her training.

It is important to be accurate in completing the application as not to create discrepancies in documentation. Inaccuracies may cause delays in the approval process.

Outline of Elements Needed for your Credentialing Application:

Although the credentialing process from hospital to hospital may vary slightly, you will likely need to submit most of the information we have outlined below. In some cases, you may begin collecting the required information/documentation before completing your residency program. With that in mind, you may want to begin collecting this information as soon as possible (i.e. Basic Personal Information and Medical Training Information).

  1. Fee – there is a fee for application, which funds third-party coordinated background checks and verification of information. This fee is typically $750 - $1,000 and varies based by the hospital. In some cases, your prospective employer may reimburse you for this fee.
  2. Basic Personal Information – This part of the credentialing application is intended to verify your identity. It includes:
    • A recent passport sized photograph
      (Note: this photo can usually be taken at a local drug store or post office)
    • A copy of your driver’s license or passport
    • Your Curriculum Vitae (CV)
    • Narrative Summary – The Narrative Summary may be required by some hospitals in addition to your CV. A narrative summary is a brief description of your professional plans and how they relate to the hospital.
    • A copy of your visa status, if applicable
  3. Medical Training Information – This part of the credentialing application is meant to verify your medical training including completion of medical school, residency, and if applicable, fellowship-training. Print or scan copies of these documents as they become available, you will definitely need this information to be credentialing at any new hospital.

    If you are already established in practice and joining us from another hospital, your previous hospital(s) should provide documentation indicating your volumes and outcomes for the past two years. Volume should reflect the number of each type of procedure you are requesting to perform at the hospital. This is the requirement of hospitals to ensure current clinical competency of its medical staff members.
    • Copy of your Educational Commission for Foreign Medical Graduates (ECFMG) certification (or equivalent), if applicable. (Note: this is only for international medical graduates)
    • Copy of your medical school diploma (Note: if you have graduated from a international medical school, please submit a certified copy of an English translation)
    • Copy of your internship certificate
    • Copy of your residency certificate
    • Copy of your fellowship certificate(s), if applicable
    • Copy of your most recent Continuing Medical Education (CME) certificate and a list of courses attended (Note: this is only for physicians who have worked outside of their residency. There are no CME requirements for recent residency graduates until two years after residency.)
    • Copy of Your Case Log - For new graduates of a residency/fellowship program your Program Director should provide a copy of this case log upon completion of your residency and/or fellowship.
  4. Licenses – this part of the Credentialing Application ensures that each new physician has an active state medical license and state/federal controlled dangerous substance registrations. This process is time consuming, so as soon as you decide what state you would like to practice in, we recommend applying for your license.
    • Copy of current New Jersey Medical License
      Note: In the State of New Jersey, you need to request this license first, before applying for other registrations.
    • Copy of current New Jersey Controlled Dangerous Substances Narcotics Registration (CDS)
    • Copy of current US Drug Enforcement Administration (DEA) registration
      • The current fee for the US DEA for physician registration is $731 for three years
      • This registration process usually takes about 30 days
      • Here is a link to the application.
    • Copy of your Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), and/or Pediatric Advanced Life Support (PALS) certification(s), if applicable
      (Note: typically these certifications are not required unless you are administering sedation… with that in mind this step is most relevant for anesthesiologists, cardiologists, interventional cardiologists, vascular surgeons, emergency medicine physicians, etc. In some cases, depending on your specialty or area of focus, your contract may require such a certification.)
    • Copy of your out-of-state license certificate(s), if applicable
    • Copy of your Specialty Board Certification
  5. Insurance – the next section of the Credentialing Application deals with malpractice insurance.
    • Copy of the face sheet of your current malpractice liability policy
      (Note: if you are a resident, you are currently under your teaching hospital’s malpractice insurance policy. You may request a copy of the policy number, carrier, etc. Your Residency Director should be able to provide direction on how to obtain a copy of this policy or direct you to the appropriate person in the Risk Management Department.

      The medical malpractice coverage provided for you as a resident, only covers you during the time you are a resident and only for the clinical activities that are within the scope of your residency program. In accordance with NJ state law, you are required to provide proof of medical malpractice insurance coverage at all times.)
    • Waiver and Release Form – this form is provided by the hospital and must be notarized! With that in mind, you must find a notary to submit this part of the application. There may be a registered notary within your GME program. Consider asking your coordinator or residency director.

      In a pinch, you can also search online for a notary, but they may charge a fee for their services.
    • Credentialing Verification Services Waiver and Release form (must be signed) – these third-party companies verify all information within your credentialing application and require your written consent to do so.
    • Authorization to Release Claim History for both Princeton, MIIX, MD Advantage, Proclaim, Promutual or State Volunteer Mutual Insurance Companies, if applicable – these insurance companies require that you provide an individual release form for their companies
  6. Your Health – this section is to confirm that you are physically healthy and able to practice medicine in a hospital
    • Purified Protein Derivative (PPD) Form – this is the form which verifies the results of the tuberculosis skin test, or PPD test. This test is an annual requirement in all acute care hospitals. (Note: You may contact RWJBarnabas Health Employee Health for additional information or for a copy of this form. RWJBarnabas Health Employee Health Services can be reached at (973) 322-6450).
    • Certificate of Health Form – This form should be completed by your Primary Care Physician, and confirms that you are physically able to exercise the clinical privileges you requested in your application.
    • Proof of Immunity Against Measles and Rubella
  7. Acknowledgements and Privileging - This FINAL section includes additional forms that certify your acknowledgement of mandatory evaluations and medical staff bylaws, as well as specific requests for privileging.
    • Focused Professional Practice Evaluation (FPPE) Form – the FPPE form is meant to inform you of a mandatory period of focused review for any physician requesting new privileges. In other words, once you are on staff at the hospital, you must have a certain number of cases during which you will be supervised and monitored by another physician. The scope of the period of supervision varies based on specialty. For example, a general surgeon may need to be supervised for the first 10 cases he/she is able to operate solo.

      For additional information on FPPE or the Ongoing Professional Practice Evaluation (OPPE) - periodic review process for physicians already on staff, please visit the Joint Commission website.
    • Medicare Physician’s Acknowledgement Notice, signed and date – this form is required for each new physician. You must list your National Provider Identifier (NPI) number.
    • Medicaid Number – As a new requirement in 2013, all credentialed physicians must apply for and submit a Medicaid Number (either as either a billing or non-billing provider).

      Differences between a billing or non-billing provider:
      As a billing/servicing physician (i.e. a Medicaid fee-for-service provider) your practice accepts and bills for Medicaid patients. Your status as a billing physician also indicates that your practice will be listed on a public Medicaid provider directory.

      **If you would like to enroll as a Medicaid billing physician, please visit Molina Medicaid Solutions Provider online enrollment form.

      As a non-billing physician, although you may treat Medicaid patients, you do not bill for these patients and your name would not be listed publicly within the Medicaid provider directory.

      **If you would like to apply for the non-billing status, you may also visit http://www.njmmis.com or contact the Molina Solutions Provider Enrollment Unit at 609-588-6036 for an application.
    • Receipt / Acknowledgement of Staff Bylaws – as a member of the medical staff, you will be expected to abide by Medical Staff Bylaws. These bylaws will vary institution to institution. So be sure to review these bylaws carefully.
    • Completed Privileging Form – if you are requesting special privileges, please include the necessary paperwork. There is a different Privilege Form for each specialty. You will be asked to check off which procedures you will plan to perform and in some cases, must also complete a test which will help confirm your ability. In terms of documentation, you will be asked to submit case logs, course certificates, and/or a letter from the Chair of the hospital you are currently performing that procedure to attest to your competency level. This part of the application is reviewed by the Department Chair and he/she will provide final approval.

      Note: if you are already a staff member, but would like to perform additional procedures based on new training, you will be asked to re-submit this Privileging Form.
    • Sedation Privileging Form – There is a separate form to request to perform moderate sedation. In order to be approved for sedation privileges, you must complete this form and have a current ACLS certification.