Medical Staff Coordinator

Department:

10116 Advocate Aurora Health Corporate - Administration: Medical Staff Services

Status:

Full time

Benefits Eligible:

Yes

Hours Per Week:

40

Schedule Details/Additional Information:

This is a hybrid role offering remote work with the ability to attend on-site meetings in either Illinois or Wisconsin several times throughout the year.Hours are generally 8:00 am - 4:30 pm, but requires virtual meeting attendance at multiple early morning and evening meetings each month.

Responsible for facilitation of all Medical Staff functions. Leads the credentialing and privileging processes, including critically analyzing practitioners’ data to create informed recommendations for Medical Staff leaders and committees. Participates in quality assessment and improvement activities of the Medical Staff, including peer review, Focused Professional Practice Evaluation (FPPE), Ongoing Professional Practice Evaluation (OPPE), and corrective actions. Ensures continuous adherence to regulatory requirements, accreditation standards, Medical Staff Bylaws, Medical Staff Rules and Regulations and Medical Staff and organizational policies and procedures. This Coordinator in Medical Staff Services plays an important role in the Medical Staff's operations, assuring medical staff governance for the 17 Wisconsin hospitals that participate in the Unified Medical Staff.  This role assures the process flow and approvals for credentialing, privileging, and appointment of medical staff members by the Unified Medical Staff, coordinating submission, review and approved by Unified Credentials Committee, Unified Medical Executive Committee, and the Board of Directors to ensure their ability to begin practicing.  This role supports ongoing practice evaluation and Unified peer review, assuring support for the physician leaders in conducting review of quality of care, supporting the medical staff governance structure, regulatory compliance and readiness, and operationalizing medical staff bylaws and policies.  

Major Responsibilities:

• Coordinates and facilitates medical staff and advanced practice professional credentialing and privileging at the time of initial appointment and biennial reappointment. Critically analyzes data to create informed recommendations for credentialing, re-credentialing, and privileging for Medical Staff leaders and committees, ensuring adherence to accreditation standards, state and federal law, and Medical Staff bylaws. Verify and analyze practitioner-specific data obtained during the credentialing and privileging for approval bodies. Identify, review and report practitioner performance data, complaints, sanctions, adverse actions, and quality of care issues in order to facilitate analysis and evaluation of current/ongoing practitioner competency by approval bodies, including Credentials Committee, Medical Executive Committee, and Governing Bodies.
• Ensures continuous knowledge of and adherence to regulatory requirements, accreditation standards, Medical Staff Bylaws and Medical Staff and organizational policies and procedures. Ensures all practices and procedures are in accordance with Det Norske Veritas (DNV), The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), Healthcare Facilities Accreditation Program (HFAP), Emergency Medical Treatment and Labor Act (EMTALA), Healthcare Quality Improvement Act (HQIA), National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), State law, Medical Staff bylaws and hospital and system-wide policies. Responsible for coordination of and survey preparation for all Medical Staff matters for regulatory surveys and audits. Reviews and implements new actions related to federal and state rulings and accrediting body standards pertaining to the functions of the Medical Staff.
• Develops, establishes, and enforces Medical Staff bylaws, rules and regulations, and policies that govern the activities of the Medical Staff and coordinates the activities of the self-governing organized Medical Staff.
• Coordinates and manages the onboarding and orientation of newly appointed practitioners to the Medical Staff, including development, implementation, and maintenance of the regulatory and legally required education. Ensures accurate entry of privileges, arranges authorization processes to allow practitioners elect