Description
Red Flag Credentialing™
Credentialing decisions carry real operational and organizational weight. Red Flag Credentialing™ was developed to support Provider Lifecycle Professionals (PLPs), Medical Staff Professionals (MSPs), and healthcare leaders in identifying, evaluating, documenting, and escalating credentialing red flags and outliers with consistency and confidence.
The environment in which credentialing teams operate continues to grow more complex. Regulatory scrutiny is increasing. Accreditation expectations are evolving. Organizational risk tolerance is tightening. In this landscape, consistent and well-documented decision-making is not optional — it is essential.
Who This Resource Is For
- Provider Lifecycle Professionals (PLPs) and Medical Staff Professionals (MSPs)
- Credentialing Managers, Directors, and Team Leads
- Medical Staff Leadership (Department Chairs, MEC members, Board Designees)
- Compliance, Legal, Risk Management, and Quality partners
- Hospitals, medical groups, managed care organizations, delegated credentialing entities, and FQHCs
What Red Flag Credentialing™ Provides
- Clear definitions distinguishing credentialing red flags and outliers
- Structured review and escalation guidance
- Risk tiering framework (Tier 1–3) to support consistent evaluation
- Credentialing Red Flag / Outlier Escalation Grid
- Accreditation body mapping and crosswalk references (CMS, TJC, DNV, NCQA, URAC, ACHC, AAAHC)
- Compliance and best practice guidance for identifying and managing credentialing risk
- Documentation models that support clear and defensible decision-making
How Organizations Use Red Flag Credentialing™
- As a training tool for onboarding new PLPs and MSPs
- To standardize escalation decisions across credentialing teams
- To strengthen committee summaries and documentation integrity
- To align credentialing, risk management, compliance, legal, and medical staff leadership
- To support consistent, defensible credentialing decisions
Important Note
This resource is designed to supplement, not replace, the requirements outlined in your organization’s Medical Staff Bylaws, Credentialing Policies, and governing documents. Final determinations, required actions, and escalation pathways must always be guided by those authoritative sources.
Contributors
This resource reflects the collaboration and expertise of:
- Heidi Thompson, MBA, CPCS®, CPMSM®, FMSP®
- Donna Goestenkors, CPMSM®, EMSP, CLE
- Nicole Keller, MSHM, CPHQ, CPHIT, CSM
- Rachelle Silva, BS, CPCS®, CPMSM®, CLE
- Joyce Moore, CPMSM, CPCS, MPA
Equip your team with a structured framework that strengthens credentialing governance, documentation clarity, and risk oversight across the provider lifecycle.
