• Serve as administrative director and advisor to the officers and leaders of the clinical Medical Staff to assure effective governance of the clinical medical staff organization in compliance with the medical staff bylaws, applicable federal and state regulations and regulatory agencies.
• Direct, maintain and evaluate the credentialing program to ensure initial appointment and subsequent re-appointment of qualified and properly credentialed physicians, and other healthcare practitioners to the medical staff as well as the proper credentialing and ongoing monitoring of all licensed, certified, and/or registered individuals providing patient care services.
• Direct, maintain and evaluate the centralized medical staff database to ensure an accurate and current database of medical staff credentials and demographics.
• Function as the primary administrative link between the medical staff officers and the institution’s senior management.

• Provide direction, counsel and support in a broad range of activities to the officers and leaders of the clinical medical staff to assure effective medical staff governance in accordance with the medical staff bylaws.
• Attend meetings, participate, facilitate and provide key support to the Medical Executive Committees and Hospital Committees, that relate to medical staff issues and functions.
• Provide appropriate communication to and liaison with medical staff leadership regarding meeting agendas, presentations, follow-up reports, etc.
• Attend and represent Medical Staff Services all DNV Accreditation and State Surveys. Ensure compliance with accreditation standards (DNV regulation guidelines (federal (CMS) and state) as they pertain to medical staff governance issues including confidentiality.
• Maintain Medical Staff organization documents such as policies and procedures, meeting minutes, credentials files, and quality files in a confidential manner as required by law. Assist with the maintenance of bylaws, rules and regulations
• Oversee the process for updates and renewals of medical staff policies ensuring appropriateness and timelines of such renewals; facilitates the creation of new clinical policies and procedures

Medical Staff Credentialing:

• Direct, maintain and annually evaluate the credentialing program with particular emphasis on supporting medical staff leadership, to appoint qualified applicants to the medical staff and to re-appoint current staff.
• Direct, maintain and annually evaluate the credentialing program for physician assistants, advanced practice nurses, all healthcare practitioners who are licensed, certified, and/or registered and offer patient care services as required by their job.
• Responsible for ensuring that the findings, conclusions and recommendations for actions regarding appointment and re-appointment are reported through the appropriate committees and leadership in a timely manner.
• Manage and analyze the collecting, aggregating and reporting of primary source verification of credentials and other key indicators such as clinical quality for OPPE &FPPE, malpractice history, disciplinary actions, etc. for use in credentialing decision-making, planning and process improvement activities. Oversee reporting of aggregate information to medical staff leadership and others as applicable.
• Oversee the management of the credentialing medical staff database
• Oversee the orientation, in-servicing and education of the staff charged with credentialing functions.
• Oversee the procedure for obtaining temporary and emergency privileges.
• Establish and maintain continuity in the planning, development and implementation of standards, policies and procedures applicable to the medical staff functions, credentialing, privileging, ongoing professional practice evaluation process (OPPE) for physicians, PAs and APNs, focused professional practice evaluation process (FPPE) for physicians, PAs and APNs, bylaws, rules and regulations, quality and administrative functions.
• Establish annual and long-term goals and plans for full range of functions consistent with institutional, division and department goals and strategies in alignment with the institution’s mission and goals.
• Develop and maintain strong working relationships with medical staff and clinical leadership and senior management.
• Act as internal and external leader for the department. Monitor and stay current with accreditation, regulatory and legal trends as they relate to medical staff and credentialing and communicate as appropriate.
• Prepare and/or oversee preparation and dissemination of reports as requested by medical staff leadership
• Provide information to Legal Services and Risk Management as requested.

• Attend staff meetings or other company sponsored or mandated meetings as required
• Perform additional duties as assigned
• Ability to work off-hours and on call when required

• Bachelor’s degree in Business Administration or healthcare-related field, Master's Preferred
• Certification from the Certification Council of National Association of Medical Staff Services (NAMSS) as a Certified Professional Medical Services Management (CPMSM).
• Minimum of 15+yrs experience in medical staff administration and credentialing in a multi-facility hospital system
• Strong knowledge of Accreditation Standards with Joint Commission and/or DNV + State and Federal Laws
• Extensive knowledge of credentialing software programs, required
• Strong proficiency with Microsoft Office (Word, Excel, and Outlook), required
• Position requires fluency in English; written and oral communication