Position Summary: Directs Medical Staff Services relative to credentialing, appointment/reappointment and evaluation of Medical Staff and Advanced Practice Professionals. Responsible for preparation, organization and follow-up involved in maintaining hospital accreditation and compliance with state, Federal and other external regulatory requirements as they relate to the Medical Staff Organization. Reporting to the VP of Quality and Patient Safety, the incumbent is responsible for all medical staff, adjunct professionals credentialing and support of the medical staff’s self governance as well as direct supervision of support staff. Essential Functions:
- Exhibits responsibility and accountability for assigned work, works independently.
- Must balance multiple tasks/projects while meeting organizational standards.
- Must be extremely detail oriented and able to follow through on all assigned tasks.
- Ability to adapt to flexible work schedules and frequent interruption.
- Plans, organizes and direct the credentialing process of the Medical Staff, Advanced Practice Professionals and Vendors to ensure that all individuals with clinical privileges are competent and maintain competency to provide patient care within the scope of their training, licensure and clinical privileges as granted by the Medical Staff and Board of Trustees.
- Develops and implements department policies and procedures with regard to the credentialing process.
- Serves as recording secretary for Credentials Committee and prepares Credentials report for Executive Committee and Board of Trustees.
- Ability to interpret and follow federal and state laws, as well as The Joint Commission standards and Medical Staff By-laws, policies and procedures.
- Works with By-laws Committee and Executive Committee developing amendments as needed.
- Educates, directs and assists Medical Staff officers, committee chairs, and other healthcare professionals in carrying out their responsibilities as outlined in the Medical Staff Bylaws, Rules and Regulations to insure compliance with Medical Staff documents, accrediting and licensure organizations, minimizing risk exposure thus protecting them and the organization from liability.
- Assists in orientation program for Medical Staff, officers, Department and Committee chairpersons.
- Maintains an ongoing thorough familiarity with the Medical Staff By-laws, rules and regulations.
- Stays current and knowledgeable regarding legal and regulatory requirements related to Medical Staff activities and conveys pertinent information to appropriate committees, departments and Medical Staff.
- Assures timely processing of medical Staff applications, appointments, credentialing actions and clinical privileging information in accordance with Medical Staff By-Laws.
- Maintains Medical Staff Data Bases for medical staff organization.
- Uses various software programs to develop, generate and update documentation.
- Maintains hard copy and PC filing systems
- Manages and directs Medical Staff credentialing staff and/or administrative/clerical staff.
- Update and maintain Physician directory database.
- Understand chain of command philosophy and follows departmental protocol for promptly reporting issues.
- Serves as recording secretary for Critical Care Committee and assists with development of Critical Care policies, orders and protocols.
- Provides administrative assistance to the Medical Staff.
- Regular, punctual and dependable attendance.
- Other duties as assigned.
Experience Required or Preferred:
- Minimum of 5 years of experience in medical staff setting required
- Knowledge of State, Federal, and JCAHO regulations. Previous credentialing and management experience in a healthcare setting preferred. Working knowledge of The Joint Commission accreditation process and standards, health care and credentialing industry, regulatory and legal requirements and other national standards preferred.
- 3-5 years’ experience as a Medical Staff Coordinator preferred
- Previous office management experience preferred
- Current Certified Professional Medical Staff Management (CPMSM) and/or Certified Provider Credentialing Specialist (CPCS) with the National Association Medical Staff Services is preferred.