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Medical Staff: UNM Hospital


UNMH Medical Staff Affairs is responsible for the following:

  • Provide support for medical staff leadership and all functions of the UNMH medical staff organization (MSO).
  • Collaborate with UNM Health's Credentials Verification Office (CVO) to receive credentialing applications following processing and primary source verification by the CVO.
  • Conduct a thorough review and verification of credentialing and privileging information so UNMH medical staff can evaluate practitioners’ ability to provide quality patient care, make recommendations to the UNMH Governing Body, and minimize risk for UNMH.

Credentialing & Privileging 

Scope of Services

The UNMH Medical Staff Office is responsible for the following:

  • Receive, analyze, identify and investigate issues requiring follow up, prepare initial and reappointment files, expansion of privilege requests, for review by medical staff leadership and committee process.
  • Perform committee follow up and notification of providers upon approval by UNMH Governing Body.
  • Collaborate with CVO to ensure update of all UNM Health System data and notification of downstream systems.
  • Manage day-to-day operations and workflow of UNMH MSO which includes oversight of the credentialing, recredentialing, privileging and appeal process.
  • Assists in clinical privilege development, maintenance and regular review of specialty-specific clinical privilege criteria.
  • Maintain accreditation knowledge and ongoing compliance with state statutes; prepare and participate in accreditation surveys, develop action plans as appropriate.
  • Facilitate medical staff in peer review process, ensuring all aspects of medico-legal process are maintained.
  • Monitor, track and ensure clinical department compliance with Ongoing Professional Practice Evaluation.
  • Coordinate and maintain the UNMH MSO governance documents:  Medical Staff Bylaws, Rules and Regulations, policies and procedures, and related documents; ensure continuing compliance.
  • Assures review of existing policies and governance documents on a regular basis and recommends changes to Medical Executive Committee (MEC) as appropriate.
  • Provides resources to the MSO leaders to assist them in carrying out their responsibilities.
  • Carries out specific tasks assigned by the MEC and/or the Chief of Staff.
  • Oversees the planning, implementation, execution, and evaluation of special projects.
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