This position manages the department and committee process of the Medical Staff organization which includes all aspects of credentialing and all aspects of privileging for an assigned facility; compliance to Medical Staff by-laws, policies, rules and regulations; subject matter expert support for the Medical Staff leadership of the assigned hospital. The position requires maintaining an understanding and knowledge of compliance and regulatory law while providing direction to Medical Staff and hospital leadership.
Responsibilities
Core Responsibilites and Essential Functions
Medical Staff Governance Management for Physicians and Allied Health Professionals * Management of all duties of Medical Staff committees and departments of assigned hospital. * Controls and directs the administration of governance documents. Ensures that all documents are compliant and current (i.e., Medical Staff Bylaws, Rules and Regulations, Policies and Procedures). * Operationalizes actions such as corrective actions including the Fair Hearing Process to include interviewing, action plan development, creation of ad hoc committees, correspondence and other communication in collaboration with Medical Staff Services leadership and the legal department. * Subject matter expert support to Medical Staff leadership, Administration, Medical Staff members and the hospital team. * Oversees the planning and management of an effective Medical Staff meeting management system. * Liaison between the medical staff, administration and the legal department * Responsible for all orientation and education of medical and allied health staff along with Medical Staff members. * Plans and manages the administrative support to Medical Staff Leadership that allows them to effectively carry out their duties and responsibilities. * Creates, interprets and analyzes data and reports related to the position. * Leads or participates in projects related to Medical Staff Services.
Credentialing * Assists in the design, implementation and management of an objective, criteria-based clinical privileging system. * Reviews and approves primary source credentialing applications processed by Credentialing Specialists and verifies adherence to privileging criteria of all Medical Staff for assigned hospital organization. * Validates appointment and reappointment process. Follows policy, standards and regulations as set by the Bylaws, Joint Commission and state/federal agencies. * Directs the use of performance improvement data by Medical Staff Leaders to make informed decisions regarding practitioner competence. * Participates in all aspects of Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) as related to the privileging functions for FPPE and OPPE in conjunction with the Quality Department. * Develops and implements a mechanism to ensure that practitioners practice within the scope of their privileges. * Accountable for the preparation and content of the Medical Staff Services Board report for assigned facility. * Develops and reports on all practitioner analytics of an assigned facility obtained during the initial application and reappointment process. * Manages credentialing process for all allied health and medical staff of assigned hospital. * Collaborates with Quality Improvement, Risk Management and Legal as needed. Responsible for and interprets all necessary reports and data to appropriate committees.
Regulatory Compliance and Continuous Survey Readiness * Responsible for compliance with all appropriate regulatory standards regarding organized medical staff and credentialing processes. * Maintains subject matter expert level knowledge of Medical Staff Bylaws, rules and regulations, policies and procedures. * Demonstrates knowledge of external accrediting standards as well as state and federal regulations regarding Medical Staff, credentialing and privileging. Ability to interpret those standards providing information to the Medical Staff and Administration. * Identifies need and participates in the development and revision of documents to ensure compliance to any external regulatory body or based on internal need. Ensures appropriate process and procedures are followed to make needed changes. * Oversight of the following duties for assigned hospital: development and distribution of monthly emergency call schedules per EMTALA, socializes and maintains all system wide medical staff documents, preparation and participation in survey activities from The Joint Commission and CMS.
Fair Hearing Process * Manages the process involving due process hearing rights provided to the Medical Staff. * Responsible for compliance to the Fair Hearing Policy and the process described within it. Partners with the legal team and other Medical Staff leaders. * Advises the Medical Executive Committee on possible outcomes including multiple levels of suspension or possible termination of privileges of physicians or allied health professionals. * Develops and/or participates in any verbal or written communication regarding this process.
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
Some high school Required or
equivalent Required and
Associate's Degree in related field such as health information or healthcare administration Preferred or
Bachelor's Degree in related field such as health information or healthcare administration Preferred
Required Minimum Experience
Minimum 3 years as a medical staff services professional within a hospital setting Required and
Experience in an integrated multi-facility system Preferred and
Additionally, experience with state/federal regulatory requirements, accreditation standards, Joint Commission and other surveys Preferred
Required Minimum Skills
Excellent verbal and written communication skill along with the ability to work with computer-based system for data entry and extraction.
Knowledge of the advanced principles of credentialing and privileging within a hospital environment.
Ability to analyze file information and other data for compliance to a process or policy.
