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Overview
Responsible for the effective management of the credentialing process for the Regional Medical Center Campus and Northport Medical Center Campus professional (medical) staff. Also responsible for the coordination of all Medical Staff department and committee meetings. Serves as medical staff credentialing resource for other facilities in the DCH System, including Fayette Medical Center. Supports and assists the organized Medical Staff in the effective performance management of its required functions in compliance with hospital and regulatory agency requirements. Serves as a link between senior management and the Medical Staff to promote and enhance good communication and a positive working relationship. Responsible for establishing, contributing, and maintaining continuity in the planning, development, and implementation of standards applicable to Medical Staff members relating to credentialing and administrative functions.
Responsibilities
• Interviews, selects, hires, and retains employees, including other management positions
• Ensures orientation and training for employees, including other management positions
• Manages performance, including other management positions
• Promotes, demotes, or transfers employees to meet organizational needs, including other management positions
• Executes progressive discipline up to and including termination
• Manages departmental productivity standards
• Manages departmental budget
• Provides strategic leadership for department(s)
• Performs long range planning and overall direction setting at the departmental level
• Responsible for department organizational structure and alignment to meet forecasted business needs
• Responsible for development, implementation and interpretation of system policies within a major organizational/functional area or the development and review of system policies within a recognized discipline
• Performs compliance requirements as outlined in the Employee Handbook
• Approves payroll and is responsible for accurate payment of employees, including other management positions
• Assures meeting/exceeding of DCH mission and vision, department goals and key areas of excellence
• Assists/facilitates Medical Staff Officers with their responsibilities for compliance with the Medical Staff Bylaws, rules and regulations in relation to the credentialing process and directs the processing of all medical staff applications (initial and reappointment) in accordance with provisions of the Medical Staff Bylaws, policies, etc.
• Responsible for the documentation concerning the activities of the organized Medical staff(s), including all medical staff appointees’ credentials files, minutes from various departmental/committee meetings and any other records of the Medical Staff.
• Accumulates and assists in preparation of materials for Medical Staff key committees including the Credentials Committee (PAC), Bylaws Committee and Executive Committee of the Medical Staff, which includes agenda packet preparation and on-going and follow-up documentation necessary for the smooth functioning of these committees.
• Provides/distributes follow-up and follow-through documentation and dissemination of key information regarding Medical Staff and/or other professional staff credentials information to RMC and NMC department/staff managers and maintains data in the Meditech provider dictionary with regard to same.
• Oversees the scheduling of Medical Staff meetings and activities, including all department/committee meetings, quarterly staff meetings, etc., with assigned administrative/department head secretaries and with other support personnel.
• Responsible for the preparation of the monthly PAC/MEC Medical Staff recommendations for RMC and NMC to the DCH Board in the form of a written Board report to the CEO’s secretary.
• Responsible for the preparation and management of the budget for the Medical Staff Office at RMC and NMC.
• Responsible for the Medical Staff bank account.
• Responsible for the department credit card and reconciliation.
• Responsible for travel, educational reimbursement.
• Supervises necessary personnel for department functioning.
• Responsible for the optimal use of the credentialing software system; including build, design, and optimization
• Responsible for overseeing the development and maintenance of the call schedules for emergency call at RMC/NMC.
• Responsible for sending invoices and the collection/maintenance of Medical Staff reappointment dues.
• Responsible for the coordination of Medical Staff activities between RMC and NMC.
• Maintains archives of all Medical Staff minutes.
• Responsible for accreditation survey preparation and compliance for the Medical Staff Offices at RMC and NMC.
• Researches and oversees the development of privileging criteria; facilitates cross-privileging and additional privilege processes.
• Directs the process of temporary privileges.
• Directs Process requests for Proctoring according to Medical Staff policies.
• Oversees Observation Requests according to Medical Staff policies.
• Oversees PGY privileging for clinical rotations and physician assistant and medical student requests for clinical rotations.
• Responsible for Performance Improvement activities in the Department.
• Responsible for the coordination, collection and assimilation of all data required to compile the performance profiles for individual Medical Staff members.
• Notifies appropriate hospital personnel of new Medical Staff members, Residents, Non-Member Practitioners.
• Oversees the process for access to the network for physicians, allied health professionals, residents, and medical students.
• Oversees the Physician Orientation program to include badge acquisition, IT access, Expanse training, generalized orientation either remotely or live, in person identification, PACS access and other departments as necessary.
• Responsible for the preparation for and participation in surveys and audits by all regulatory agencies.
• Responsible for the Medical Staff Bylaws, Medical Staff Policies and Rules and Regulations of the Medical Staff.
• Responsible for Medical Staff Leadership and Department Chair orientation and education.
• Oversees the credentialing process: pre-applications, reappointments, and initial applications for prospective members, Licensed Independent Practitioner Employees, AHPs, residents, students, observations, scribes, external proctors, and others as appropriate.
• Processes all initial and reappointment applications for Medical Staff membership.
• Processes all reappointment applications for Allied Health Professionals, excluding Emergency Medicine, Anesthesia, and Internal Medicine.
• Processes incoming Family Medicine Residents
• Processes all external proctoring request(s).
• Coordinates receipt of credentialing and privileging applications following processing and primary source verification; performs review and analysis, identification and follow up of “red flag” items; prepares files for review and recommendation by the medical staff.
• Coordinates credentialing end-of-committee process to ensure notification of providers, departments and leadership; database updates; computer access, initiate badge request/access, maintain and update Rolodex and physician.
• Maintain and update provider emails in distribution lists.
• Maintains a current master copy of Medical Staff Bylaws and Rules and Regulations, Policies and Procedures.
• Initiate and publish Monthly Downtime documents, provider contact information, Board action report, Management
• Attends, schedules (room reservation, catering, meeting invite), coordinates, prepares agenda, prepares presentation, prepare packets, takes minutes, provides follow up for medical staff committees and/or meetings.
• Prepares summary reports of credentialing/privileging recommendations and ensures flow of information and action items for medical staff committees outlined in the Medical Staff Bylaws.
• Interprets federal, state, local, and government/insurance agency regulations and guidelines, as well as DCH RMC/NMC Medical Staff Bylaws, rules and regulations, policies and procedures; advises providers, management, and administrators on compliance issues as appropriate.
• Generates letters, queries and reports from credentialing and privileging database and reports any findings to Senior Administrator; i.e.; monthly, quarterly, biannual -as appropriate (ex. OIG, AL Medicaid, board letters, reports to MEC, Board Report.
• Responsible for clinical privilege development and maintenance of the entity privilege database.
• Performs miscellaneous job-related duties as assigned; i.e., data entry, filing, ordering supplies, incoming/outgoing mail, scanning, correspondence.
• Responsible for coordinating, scheduling and preparing for MSS or Physician events (ex. Doctors Day)
DCH Standards:
• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues.
• Requires essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.
Qualifications
• General Education:
• At least an Associate degree. Bachelor’s degree in health sciences, education or business preferred.
• Certified Professional Medical Services Management (CPMSM) preferred, or ability to acquire within timeframe allowable by the National Association of Medical Staff Specialists required.
• Four years progressive experience in working with physicians in a hospital/health system environment required acquired through a combination of medical staff affairs experience and/or management experience with substantial physician interactions.
• Supervisory experience or management experience required.
• Aptitudes:
• Excellent verbal and written communication skills
• Ability to remain objective and calm in highly stressful situations
• Accuracy and neatness in work habits
• Must be able to read, write legibly, speak, and comprehend English.
• Machines, Tools and Equipment Required to Operate
• Telephone System
• Automated Answering System
• Copier
• Personal computer and printer
• Transcription Equipment
• FAX machine
WORKING CONDITIONS
Interpersonal Relationships:
• Contact with physicians, senior leadership, front level employees, physician’s office staff via telephone, e-mail, face to face
• Lead and coordinate credentialing and privileging processes
• Interact with external surveyors
• Communicate with vendors, surveyors, data requestors via telephone, email, face to face
• Encounters conflict daily
• Does not require protective or safety equipment
• Regularly writes memo and letters
• Rarely engages in public speaking
• Responsible for the work outcomes of the Department
• Often requires creative thinking and problem solving skills
• Delegating, organizing, planning and prioritizing work is a necessity
Physical Work Conditions:
• Light work-lifting up to 20 pounds with frequent carrying of up to 10 pounds.
• Significant sitting and walking
• Involves stair climbing, stooping and crouching, reaching and keyboarding
• Vision and hearing normal to correctable to normal
• More than 95% of work day is spent indoors in climate controlled environment
• Able to perform the duties with or without reasonable accommodation
• Hearing and vision must be normal or corrected to within normal range.
• Physician presence on site is essential
Structural Job Characteristics:
• Works 40 hours per week
• Self-motivated and independent work
• Daily work with departmental software
• Environment structured with requirement to follow processes exactly
• Large degree of variability in daily work
• Monthly deadlines must be met
