CPMSM Exam Content Outline
The CPMSM exam addresses the following content. Candidates are required to demonstrate proficiency by answering exam questions that evaluate their knowledge of facts, concepts and processes required to complete the tasks described below. Additional information is available in the Candidate Handbook.
Manage, Conduct, Participate In, and Maintain Credentialing and Privileging Processes (38-44%)
- Uniformly apply clearly defined credentialing and privileging processes to all practitioners/providers in accordance with regulatory requirements, accreditation standards, and organizational policies and procedures to mitigate organizational risk (e.g., negligent credentialing, discrimination) and promote thedelivery of safe, quality patient care.
- Direct and/or perform initial or reappointment/re-credentialing processes for eligible practitioners/providers to ensure compliance with organizational policies, accreditation standards, and regulatory requirements.
- Evaluate credentialing/privileging requests and evidence of education, training, and experience using established criteria for all applicants to determine eligibility for requested privileges, membership, and/or plan participation.
- Comply with internal and external requirements related to verifying the status of all practitioner/provider expirables (e.g., licenses, certifications, insurance) by querying approved sources and recommending action(s) to medical staff, medical executive committee, and/or organizational leadership based upon bylaws and policies/procedures (e.g., automatic suspension).
- Analyze and prepare practitioner/provider performance improvement and quality/peer review data in clear, concise, and structured reports and presentations using a variety of analysisand reporting tools in order to facilitate review by the appropriate organizational leadership (e.g., credentials committee, department chair, medical executive committee) in accordance with organizational policies to enable evaluation of current/ ongoing practitioner/provider competency.
- Collaborate with the organization’s medical staff to develop and maintain a facility-specific, criteria-based clinical privileging system in accordance with regulatory requirements, accreditation standards, and organizational policies and procedures.
Ensure Compliance with Accreditation Standards and Regulatory Requirements (24-30%)
- Develop and/or update applicable governance documents (e.g., medical staff bylaws, credentialing policies and procedures, rules and regulations) that support and direct organizational practices and that comply with regulatory requirements, accreditation standards, and organizational policies and procedures.
- Facilitate efficient and cost-effective due process that complies with an organization’s fair hearing and appeals policy as well as applicable legal and regulatory requirements (e.g., State and U.S. Federal Laws, Centers for Medicare and Medicaid) by serving as an advisor to organizational leadership (e.g., medical staff, administration) in order to ensure uniformity and fairness.
- Identify and report adverse actions taken against a practitioner/provider by notifying the appropriate authorized agencies, organizational staff, and external organizations in accordance with applicable law and contractual requirements.
- Monitor and/or report sanctions and complaints for all practitioners/ providers to recommend action by medical staff and/or organizational leadership in order to comply with internal and external requirements (e.g., State and Federal agencies and health plans).
Manage Departmental Operations and Facilitate Medical Staff Functions (29-35%)
- Prepare and review operational budget and staff plan(s) that support medical staff services and credentialing functions by evaluating financial and resource information (e.g., bylaws, policies and procedures, accreditation standards, regulations, industry staffing analyses, productivity reports, and strategic plans and reports).
- Audit, assess, procure, implement, effectively utilize and maintain practitioner/provider credentialing processes and information systems (e.g., files, reports, minutes, databases) by analyzing the needs and resources of medical services/credentialing in order to manage data with efficiency and integrity in a manner that complies with regulatory requirements, accreditation standards, and organizational policies and procedures.
- Develop policies and applicable tools (e.g., confidentiality statements, audit tools) that govern the efficient management, sharing, and distribution of information to internal and external stakeholders (e.g., recruitment, provider enrollment, peer review committees, hospital staff privileges) in accordance with regulatory requirements and accreditation standards.
- Work independently and/or with others, prepare materials for medical services/credentialing committees, boards, and other organizational groups in order to maintain an official record of proceedings and decisions and to identify and ensure follow-up on action items (e.g., scheduling, agendas, meeting materials, action plans).
- Work independently and/or with others, coordinate educational activities offered by the organization to assist practitioners/providers in meeting their education requirements or provide additional learning opportunities.
- Collaborate with others to create and implement orientation and ongoing education about organizational programs, policies, and practices (e.g., patient and staff confidentiality, safety, infection control, risk management, impairment, credentialing) that support practitioners/providers and leadership compliance with accreditation standards and regulatory requirements.