Employment Type:

Full time

Shift:

Day Shift

Description:

Purpose

This position is an integral part of the Medical Staff Services Team and is accountable for meticulously following regulatory standards, federal and local statutes, credentialing policies and procedures, and maintenance of an accurate physician data base. This role also serves as a guide for practitioners in navigating organizational requirements; serves as a resource for internal and external stakeholders; and participates in the development implementation of process improvement initiatives. Uses independent judgement and problem-solving skills demonstrating discretion and sound judgement in the decision-making process. Functions independently, with little or no day-to-day supervision.

Essential Functions

Medical Staff Liaison: 

• Serves as primary point of contact for assigned specialties to ensure provider and stakeholder satisfaction across multiple hospitals, ensuring consistency and quality in service delivery.
• Ensures coordination and alignment of medical staff services processes and procedures across the region, promoting a cohesive and collaborative environment.
• Assists providers and stakeholders in navigating organizational requirements, addressing concerns, and facilitating effective communication to promptly resolve issues. Maintains a customer-focused attitude, good rapport, and cooperative relationships. Approaches conflict in a constructive manner. Helps to identify problems, offer solutions, and participate in their resolution.
• Develops strong relationships with medical staff and administrators across THMI, understanding needs, preferences, and goals to ensure satisfaction and trust. Works closely with department leaders to ensure needs are met and expectations are aligned.
• Interprets and conveys medical staff requirements clearly to internal teams and external stakeholders with updates and information as needed.
• Provides training and support to medical staff and medical staff leaders within assigned specialty areas on credentialing and privileging processes, regulatory requirements, and hospital policies.
• Orients new medical staff leaders to MSS processes and applications.
• Serve as a liaison between medical staff, hospital administration, and external regulatory bodies.

Onboarding and Ongoing Support:

• Manages all elements of assigned medical staff specialty areas, including the onboarding of new applicants to the medical staff, analyzing information to determine eligibility and demonstrated competence, required follow-up to ensure rapid completion of applications to meet target dates for completion while exercising sound discretion and professional judgement in decision making.
• Monitors CPI progress and alignment of medical staff process to ensure timely progress and compliance with target dates of completion.
• Manages the reappointment, request for change and resignation processes.
• Ensures compliance with FPPE requirements and timelines for completion.
• Meets processing time thresholds consistently and with minimal error.

Regulatory Compliance and Accreditation: 

• Ensures compliance with all relevant regulatory and accreditation standards, including Joint Commission, CMS, and state-specific requirements.
• Manages the credentialing and privileging processes for medical staff, ensuring all necessary qualifications and standards for compliance with regulatory, statutory and hospital requirements are met.
• Assists in the direction and maintenance of a comprehensive and specialized credentialing program to assure continued accreditation by The Joint Commission (TJC) and other regulatory organizations, including assistance with accreditation surveys.
• Serves as a resource to interpret, explain, and follow all regulatory guidelines, including medical staff bylaws, rules and regulations and polices. Maintains a working knowledge of applicable Federal, State and local laws/regulation, and organizational policies and procedures in order to ensure adherence.
• Monitors delineation of privilege forms to ensure they reflect current standards in training, competency requirements, and standard of care, as well as the identification of necessary changes and opportunities for alignment.
• Assists with the development and maintenance of privilege request forms, policies and procedures.

Quality Assurance and Improvement: 

• Performs ongoing Data Analysis, auditing and maintenance of the Medical Staff database and supporting documentation to ensure data and information integrity to support internal practices and the data integrity of the patient-facing marketing website.