The Manager of Medical Staff Office administers the medical staff credentialing, privileging, appointment and reappointment process, and assists the medical staff in supporting the organization’s mission, vision, and goals.

MAJOR JOB OBJECTIVES AND RESPONSIBILITIES:

The Manager of Medical Staff Services will be responsible for maintaining compliance with applicable regulatory agencies, i.e., Centers for Medicare/Medicaid Services (CMS), The Joint Commission (TJC), California Department of Public Health (CDPH), DHS; federal and state regulations; bylaws, rules and regulations of the medical staff and hospitals and policies and procedures related to the medical staff.

Oversees all administrative duties such as employee hiring, training, development, evaluation, job description development, policy development and new employee orientation.

Demonstrates responsibility and accountability for departmental services. Serves as a liaison in ensuring Medical Staff applications, appointments, privileges, credentialing, and administrative support services for the medical staff, and appropriate health professionals are coordinated in a thorough, accurate and timely manner. Ensures that minutes accurately reflect discussions and actions taken in associated medical staff meetings.

Ensure timely and efficient process by coordinating the credentialing and privileging of new physicians through the maintenance of credentialing database system.

Applies the principles of continuous quality improvement in delivery of services, through assessment and monitoring of medical staff services department, processes and systems; analyzes trends and implements change as required.

Ensures Medical Staff Office and credentialing program is in compliance with Medical Staff standards, The Joint Commission, legal and all regulatory and accrediting agency standards. Interprets, explains and follows all regulatory guidelines, including medical staff bylaws, fair hearing plan, rules and regulations and policies.

Works collaboratively in an interdisciplinary team approach to ensure physician concerns are addressed through established medical staff processes.

Coordinates with quality department to ensure facilitation of both Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE).

In coordination with risk manager, ensures timely and proper notification regarding any probable claims involving peer reviewed cases.

Continuously evaluates work process and design; understands role in ensuring quality/performance improvement, productivity, and service delivery to meet stakeholder needs.

Plans activities of the Medical Staff Committees, as well as, provides direction and oversight for personnel preparing and maintaining ER call schedules. Supports the Chief of Staff, Chiefs of departments, and the Chief Medical Officer in the context of their responsibilities and credentialing roles.

Performs other duties as assigned by the Chief Medical Officer and Chief Executive Officer

Serves as key liaison to clinical department administrators, department heads and other personnel regarding the clinical faculty employment, credentialing processes and development of Delineation of Privileges Forms to ensure that all credentialing is a criteria-based system.

Utilizes any computer software program(s) necessary to support the credentialing process and maintains the centralized physician/provider database including data entry and scanning of appropriate documents directly into database; maintains data sufficient to pre-populate applications supported by database.

Qualifications

Education/Certification:

BA/BS degree from an accredited college or university

Current Certified Professional Medical Staff Management (CPMSM) with the National Association Medical Staff Services or ability to obtain within 12 months.

Work Experience:

Minimum one to three years of experience in a medical staff office

Knowledge of State, Federal, and Joint Commission regulations. Previous credentialing and management experience in a healthcare setting preferred

Working knowledge of accreditation process and standards, health care and credentialing industry, regulatory and legal requirements and other national standards.

Demonstrated success and experience in medical staff services

Experience working with governance processes essential

Significant experience and knowledge in working with other healthcare organizations such as hospitals, managed care, credentialing verification organizations and ambulatory care

Other Skills, Abilities & Knowledge:

Knowledge of Medical Terminology

Ability to maintain a high degree of confidentiality and diplomacy

Effective written and verbal communication skills; able to communicate with various individuals both inside and outside the organization

Proficient with computer systems including but not limited to MS Office

Excellent written and verbal communication skills.