The Assistant Vice President (AVP) Medical Staff Services at WellStar Health System reports directly to the Vice President Medical Staff Services. The AVP provides leadership to the Medical Staff Services, Provider Credentialing and Peer Review teams. This position has strategic responsibility for developing and maintaining a high quality, comprehensive Medical Staff Services program supporting the institution's mission, values and strategic plan. This is a highly visible, hands-on leadership role with opportunity for significant organizational impact.
This position has the oversight for the implementation of successful programs for credentialing, privileging, by law management, policy management, legal issues, adverse action support, workflow processes for on time processing of applications, the execution of the OPPE/FPPE and peer review programs and building a collaborative environment for all interdependent departments.
The individual in this role maintains responsibility for monitoring all applicable regulatory laws and statutes (state and federal) and accreditation standards. These include, but are not limited to, system compliance with State, CMS, FDA, and Joint Commission requirements.
The AVP Medical Staff Services has overall responsibility of the daily operations of Medical Staff Services and Peer Review. This includes financial accountability, management development, human resources issues, and customer service strategies. The position is responsible for the strategic and tactical balance and achievement in driving Medical Staff Services service delivery and operational excellence to facilitate world-class healthcare to the patients and communities served by WellStar Health System.
As WellStar Health System expands services into new communities across the State, Medical Staff credentialing, peer review and onboarding becomes more complex in a highly integrated System. The AVP Medical Staff Services joins WellStar at an exciting time of expansion and innovation and this leader will be crucial to facilitate the consistent, reliable, timely services to credentialed providers in support of a high quality, safe patient care and a word-class patient experience.
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Responsibilities
Core Responsibilites and Essential Functions
Strategic Planning and Comprehensive Leadership of all Medical Staff Services Functions * Accountability for human capital, financial, programmatic and quality performance, regulatory oversight, standardization related to human resources * Sets prioritization of operations to achieve system objectives while assuring continuous quality improvement and outcome excellence for the Human Resource function * Develops operating and capital budgets; monitors to insure variance analysis and resolution * Identifies high risk areas for regulatory compliance; trains staff, monitors and insures compliance * Monitors HR performance outcomes via benchmark analysis and facilitates accountability via defined expectations and goals * Develops departmental/Division strategic plans and works with leadership to facilitate goal achievement
Medical Staff/Support Functions * Oversees support of Medical Executive Committee, Departments, and Medical Staff Committee for each Hospital which requires * Responsible for Corrective Action support, including Fair Hearing process * Functions as Resource/Guidance for Medical Staff Leadership, Medical Staff in general, Medical Directors, and Administrators/Senior Leadership * Oversight of Medical Staff, Allied Health, and Leadership Orientation/Education/Development * Responsible for submission of monthly reports to WellStar Medical Affairs Committee and WellStar Governing Body including any new or revised documents including, but not limited to Medical Staff Bylaws, Rules & Regulations, Policies & Procedures, privileging criteria and forms, etc.
System Credentials Functions * Oversight of credentialing/privileging for Medical Staff and Allied Health Professionals, Physician Group, PHO, and delegated credentialing for managed care organizations for all appointments and reappointments. * Assure appointment and reappointment process initiated and completed per policy, Joint Commission standards, and state/federal regulations. * Responsible for maintenance of current, individual credential file for each Medical Staff Member and Allied Health Professional. * Assures appropriate interface with Quality Improvement and Risk Management regarding credentialing/ privileging assessments and issues. * Oversight of communication with all applicants regarding membership and privileging. * Oversees processing of emergency Non-Staff Temporary privileges, processing of locum tenens privileges, processing of students/residents, credentialing of Hospice applicants, and disaster privileging. * Responsible for physician master file in EPIC. * Responsible for submission of monthly Credential Reports to WellStar Medical Affairs Committee and WellStar Governing Body.
Regulatory Compliance/Continuous Survey Readiness * Responsible for compliance with all appropriate regulatory body standards, state requirements and procedures. * Demonstrates accurate knowledge of internal Medical Staff Bylaws, Rules and Regulations, and Policies and Procedures. * Demonstrates accurate knowledge of external accrediting standards as well as state and federal regulatory requirements. * Provides Medical Staff and Administration/Senior Leadership with appropriate interpretation of standards and regulatory requirements. * Coordinates and participates in development and revision of documents to ensure compliance. * Assures Medical Staff compliance to internal and external regulations and standards. * Oversight of development and distribution of monthly emergency call rosters per EMTALA regulations * Interpret latest recommendations of Joint Commission standards in reference to Medical Staff and credentialing/ privileging. * Responsible for Medical Staff Services preparation and participation in surveys conducted by Joint Commission, CMS, FDA, State, etc. * Serve as liaison between Medical Staff and Hospital Attorney on medico-legal issues as needed.
Oversees Focused Professional Practitioner Evaluation (FPPE), Ongoing Professional Practitioner Evaluation (OPPE) and the Reappointment/Privileging process of all members of the medical staff and advance practice professionals. * Collaborates with appropriate hospital leadership to develop and implement a well harmonized process for the initial and ongoing evaluation of medical staff and APP's in support of the appointment and credentialing processes. * Oversees development of indicators and thresholds for evaluation purposes working collaboratively with various medical staff leaders. * Develops tools, procedures and process flows to support consistent application. * Establishes and standardizes reports for consistent and equitable comparisons. * Oversees the monitoring cycle of all providers; initial, ongoing and when new privileges are requested. * Monitors and evaluates the effectiveness of the process and the consistency of application. * Monitors the analysis of practitioner performance and ensures that proper methodology and analytical skills are used related to practice patterns and trends interpretation. * Advices on questionable and adverse trends for appropriate action and follow up. * Directs the coordination of Medical Staff, Quality Improvement and Performance Improvement meetings.
Oversees, organizes, and synchronizes, all Focus Physician Performance Evaluations for Concern (FPPE-C) across the system. * Assists with development of action plans for focus physician performance evaluation. * Influences or recommends chart review volume and provides alternative methods for conducting reviews. * Develops checklists for chart reviews and obtains consensus prior to implementation. * Monitors action plans to ensure compliance with established objectives and dates. * Collaborates with Quality Improvement staff, MSO, medical directors/VPMA's and other system staff to ensure collection of proper documentation. * Routinely reviews all activities, action plan updates and facilitates necessary adjustments. * Routinely reports all FPPE-C's to the AVP of the division, designated quality/Sr leaders, and medical directors/VPMA's.
Required for All Jobs
Performs other duties as assigned
Complies with all WellStar Health System policies, standards of work, and code of conduct.
Qualifications Required Minimum Education:
Bachelor's Degree Required and
Master's Degree Preferred
Required Minimum Experience
Minimum 10 years 12 years' experience as a medical staff services leader within a highly integrated health system Required and
Minimum 5 years at the director level or above Required and
Expertise in Medical staff credentialing/privileging process, comprehensive knowledge base of state/federal regulatory requirements and accreditation standards for an organized medical staff. Required and
Experience with multiple medical staff departments and committees and supervisory responsibility for three or more support staff. Required and
Expertise in medical staff governance, including practitioner credentialing and privileging processes and the Joint Commission standards addressing medical staff organizational requirements. Required and
Demonstrated success with Joint Commission survey experience including the preparation of medical staff for interview and file review components of the survey and attendance/participation in previous survey. Required and
Experience with federal/state laws and regulations relevant to medical staff functions and have the ability to draft needed revisions to documents required for compliance. Required and
Successful implementation and oversight of a system peer review and OPPE/FPPE process.
Required Minimum Skills
Knowledge of regulatory compliance and provider peer review, safety metrics, and culture change.
Ability to develop collaborative relationships and effectively execute project management plans.
Excellent communication/presentation skills, flexibility, ability to multi-task, organization skills to support a multi-hospital system.
Experience with electronic provider databases, such as ECHO.
Required Minimum License(s) and Certification(s)
Cert Prof in Med Service Mgmt. Required
Additional Licenses and Certifications
Current certification by the National Association Medical Staff Services (NAMSS) for Certified Professional in Medical Services Management (CPMSM) Required
