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Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority as integrated effective July 1, 2015, including the legacy operations and staff of
University of Wisconsin Hospital and Clinics and University of Wisconsin Medical Foundation.
Policy Title: Licensure/Certification/Registration
Policy Number: 9.41
Effective Date: July 3, 2017
Chapter: Human Resources
Employees whose positions require licensure/registration/certification must abide by such requirements as
a condition of employment and/or Medical Staff Bylaws. UW Health (UWH) must have documented
verification of the current licensure or certification of all applicable health care professionals, as required
by law, professional certification requirements, and/or position descriptions.
II. POLICY ELEMENTS
UWH requires employees to maintain a valid professional license in the state where their work is
performed. This ensures that the services that are provided and billed for are authorized and allowed for
by the various licensing agencies.
Employees and privileged providers are responsible for maintaining a valid professional license. Failure
to maintain current licensure/registration/certification may result in disciplinary action and/or termination
All departments must verify that their staff has current licensure or certification required and consistent
with the scope of services provided. The required licenses and certifications for any position will be
identified in the position descriptions or Medical Staff Bylaws. All verifications must be completed via
the primary source and documentation of verification must be maintained and tracked in PeopleSoft.
Documentation for providers credentialed by Medical Staff Affairs is kept in the credentialing files
maintained by Medical Staff Affairs. Documentation of licenses for Graduate Medical Education (GME)
trainees is kept in MedHub.
III. PERSONS AFFECTED
This policy applies to all regular and temporary employees, who are required by law or UWH
requirement to be licensed or certified. This policy also applies to providers subject to the Medical Staff
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1. Verification at Time of Hire: The Recruitment department within Human Resources (HR)
shall verify licensure/certification as part of the new hire process. This verification must: 1)
be completed via the primary source, 2) completed prior to hire date, and 3) the verification
must be documented, including date of verification. Additionally, the verification must be
entered into PeopleSoft.
2. Verification of Renewal: Each administrative or clinical department must have a procedure
in place to ensure that each staff member's licensure/certification is current. This
verification must: 1) be completed via the primary source, 2) completed prior to expiration,
and 3) the verification must be documented, including date of verification. Additionally, the
verification must be entered into PeopleSoft prior to the date of expiration.
3. Employees have an ongoing obligation to inform their supervisor if their license or
certification to practice expires, is suspended, or revoked. An employee whose
licensure/certification is not current or has been suspended or revoked will be immediately
removed from patient care responsibilities, and placed on an unpaid administrative leave. If
the employee cannot provide proof of a valid licensure/certification within a reasonable
period of time; his/her employee may be terminated.
1. The Department of Nursing and Patient Care Services will monitor and enforce this policy
for UWH nursing staff.
2. Compact Licenses: A Nurse Recruiter within Human Resources, will inform all new RN
hires that they must obtain a Wisconsin license by their employment start date, unless they
live in a compact state. If the new hire is relocating to Wisconsin from a compact state,
there is a 30-day grace period to work under that license; however, it is strongly
encouraged that the employee begins employment with a Wisconsin RN license. If a new
hire relocating from a compact state has not obtained a Wisconsin license within 30 days,
their employment may be terminated.
C. Physicians and Others Providing a “medical level of care.”
1. Graduate Medical Education (GME) Trainees: All GME trainees (residents and fellows) in
training programs sponsored by UWHC will have primary source verification of an
appropriate Wisconsin medical license by the GME Office. The GME Office will monitor
and enforce this policy. Verification of appropriate licensure of GME trainees from other
sponsoring institutions (visiting residents) will be performed by the GME Office when
rotating with UWHC sponsored programs. GME trainees sponsored by UW School of
Medicine and Public Health (UWSMPH) will have Wisconsin license verification
performed by UWSMPH with documentation provided to UW Health by request per the
2. Medical Staff Affairs will perform verifications of Wisconsin licensure and/or certification
for medical staff and other credentialed providers providing a “medical level of care”.
Verifications for providers who are not credentialed through Medical Staff Affairs will be
completed by Human Resources and/or the appropriate clinical department.
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This Policy creates no rights, contractual or otherwise. Statements of policy obtained herein are not made
for the purpose of inducing any person to become or remain an employee of UWH, and should not be
considered "promises" or as granting "property" rights. UWH may add to, subtract from and/or modify
this Policy at any time. Nothing contained in this Policy impairs the right of an employee or UWH to
terminate the employment relationship at-will.
Senior Management Sponsor: VP, Human Resources Operations
Author: Director, Employee Relations
Reviewer: Director, House and Medical Staff Administration
Approval Committee: UW Health Administrative Policy & Procedure Committee
UW Health Chief Administrative Officer