Manager- Medical Staff Office

Job Description

The Medical Staff Services (MSS) department serves as a liaison between the medical staff and hospital administration and assists the medical staff in fulfilling their responsibilities as required by local, state, federal, and other regulatory agencies. MSS serves as a resource for all members of the medical staff and hospital administration. Personnel in the Medical Staff Services department perform major functions related to the credentialing, privileging, peer review and communication with the Medical Staff and Ancillary Staff.

Working closely with the Director of Medical Staff Services, the Manager of the Medical Staff Office will supervise designated medical staff functions and processes of the Medical Staff Office. This individual will additionally support policy development, privileges development, bylaws and rules/regulations interpretation, Joint Commission standards, and other applicable federal, state, and local regulatory and/or accrediting agencies.

This individual will work to contribute to the strategic goals of the organization, the Planetree mission and goals of the department, specifically as it relates to the Medical Staff Bylaws, Joint Commission, and other applicable federal, state, and local regulatory and/or accrediting agencies standards.

Responsibilities

Develops Policies and Procedures in conjunction with the Medical Staff Bylaws and Joint Commission (TJC) regulations.

Supervises the credentialing staff (3.0 FTEs) of the Medical Staff Office. Manages and Oversees the Medical Staff initial and reappointment processes, working closely with the Senior Credentialer, to ensure that all individuals with clinical privileges provide services within the scope of their training, licensure, and individual privilege status.

Organize and support the onboarding and orientation of new medical staff members.

Ensure the MSO Database is maintained and updated in conjunction with the Senior Data Analyst, Senior Credentialer, and credentialing staff. Interfaces and coordinates with other departments as needed. Perform systems analysis as required.

Keeps current with all accreditation standards and legal requirements, alerting appropriate personnel regarding those changes. Responsible for regulatory compliance in the medical staff office, updating Medical Staff Bylaws, rules and regulations as needed in conjunction with TJC regulations.

Working with Department Chairs and MSS Director, review and update clinical privileges in all specialties.

Attends select medical staff committee meetings (Credentialing Committee, Bylaws Committee, etc.) Works with Senior Credentialing Coordinator to follow-up as necessary and gather information for meetings to assure well-organized and effective meetings. Prepare and disseminate minutes in timely manner. Coordinate with staff to prepare files for presentation.

Audit: organize and manage audits (TJC, internal audits) in collaboration with the Senior Database Analyst, Senior Credentialer, and the Director of Medical Staff Services and Compliance Department.

Establishes appropriate follow-up procedures within all areas of responsibilities to insure efficient and timely responses to requests, and promote effective customer service, and efficient office operations.

Medical Staff Services Support and Special Projects

Project Coordination - Initiate and follow through with projects in conjunction with the Director of Medical Staff Services.

Evaluates work redesign options and coordinates detailed action plans to facilitate process changes.

Streamline current processes and utilizes project management and process management tools to do so.

Collaborate with Communications Coordinator in the management of MedNews Plus for Medical Affairs. Organize, maintain and promote MedNews Plus membership for all Medical Staff Members and affiliated entities.

Assists with other projects as requested by Director, especially related to IS, HIM, Education and Development.

Supports assigned staff in work related to medical staff committees as needed. This may include the Medical Executive Committee, Bylaws Committee and others as needed..

Collaborate with Senior Credentialer to maintain Credentials/Quality files in order to preserve an organized credentialing filing system.

Monitors the expirable process for all medical staff and ancillary staff, ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures.

Participates in performance improvement by conducting internal audits of the Credentials/Quality files and data analysis.

Responsible for the preparation of the Quarterly Medical Staff Meeting and Holiday party.

Performs other related duties as assigned or requested to maintain a high level of service.

Completes required continuous training and education, including department specific requirements.

Demonstrates professional work behavior by following Service Standards and Success factors. Complies with departmental organizational policies and procedures and adheres to external agency requirements.

Qualifications

• Bachelor's Degree or higher degree preferred. A combination of medical staff services experience and relevant education may be considered as equivalent.
• Medical Staff Office experience required.
• Prior Supervisory experience is required.
• NAMSS Certification (CPCS or CPMSM) preferred. If not certified, Candidate would be required to achieve certification within two years.
• Strong interpersonal skills are required with broad based experience with staff and physicians at all levels.
• Excellent oral and written communication skills.
• Individual must exhibit a high degree of responsibility for confidential matters. Must be able to work independently and as a team member..
• Knowledge of credentialing systems and databases.
• Prior experience and knowledge of clinical privileges development preferred.
• Knowledge of Joint Commission, Federal and State requirements required.
• Ability to function in a demanding environment, navigating multiple projects simultaneously, and effectively supporting a busy medical staff office.
• Ability to coordinate large scale detail intensive projects spread over many months with many Joint Commission and Medical Staff Bylaws driven deadlines.
• Knowledge of Database administration. Proficient in Microsoft Word, Excel, and Outlook. Knowledge of Project Management is a plus.