Provides leadership, management and operational oversight of medical staff office and services.  In collaboration with the Director, CMO, medical staff officers and other medical staff leaders, plans, organizes, directs and coordinates programs and activities of the medical staff to assure strategies of the MSO are supported and goals and plans are realized. Provides oversight and co-leadership in the development and initiation of a LMC Graduate Medical Education Program. Responsible for Provider Peer Review oversight; ensures Peer Review functions are carried out in timely and confidentially.

Minimum Education: Bachelor's Degree from an accredited institution/program or other equivalent education in business, medical staff office procedures or related field.
Minimum Years of Experience: 5 Years of experience in the management and coordination of Medical Staff Office Operations
Substitutable Education & Experience (Optional): None.
Required Certifications/Licensure: CPMSM Certification (Certified Professional Medical Staff Management) or must become certified within one year of hire into role and maintain with required CEs thereafter
Required Training: Hospital MSO experience or demonstration of deep understanding of medical terminology and processes; Demonstrated successful experience at leadership and team building; Effective professional business written and verbal communication skills; Demonstrated excellent organization and time management skills and ability to manage multiple priorities effectively. Technical knowledge of automated support system and office software.
 

• Reports directly to the Director of CQO/MSS for MSO management and operations and indirectly to the VP/CMO for medical staff/provider issues.
• Directs daily operations of the Medical Staff Services Department, maintaining effective and efficient systems.
• Responsible for the fiscal and personnel management of the Medical Staff Services Department
• Direct reports include Administrative Assistant and Medical Staff Coordinators responsible for credentialing.
• Ensures that the medical staff by-laws, rules & regulations and fair hearing documents are current, reflect current practice and are consistent and in compliance with all standards and regulations. and assures medical staff awareness and compliance to each.
• Manages the medical staff and allied health credentialing program to include initial appointment, annual review, reappointment, proctoring, and privileging in accordance  with regulatory, accrediting agency and bylaws requirements.  
• Plans, organizes and directs a centralized, comprehensive credentialing program for the medical staff and allied health PR actioners.
• Coordinates medical staff activities and acts as a liaison between the medical staff, nursing and other clinical staff, and administration to ensure the administrative responsibilities of the Medical Staff are met.
• Responsible for all Medical Staff meetings:  agendas, organization, and prep of the Medical Staff Chair.
• Provides technical and administrative support to the Medical Staff Officers, Medical Staff Department and Committee leaders and other medical staff members.
• Develops and publishes the Medical Staff Calendar no less than monthly.
• Oversees timely preparation, distribution and current maintenance of Medical Staff Call Schedules for Emergency Department unassigned call.
• Maintains knowledge and compliance of current CMS/DNV medical staff standards as well as state and federal requirements.
• Ensures that the medical staff by-laws, rules & regulations and fair hearing documents are current, reflect current practice and are consistent and in compliance with all standards and regulations. and assures medical staff awareness and compliance to each. 
• Maintains the master copy and working knowledge of the Medical Staff Bylaws, Rules and Regulations, Policies and Procedures.  Assists in Medical Staff compliance and regular review to maintain current and complete documents.
• Assists in orientation of new Medical Staff members, Medical Staff Department Chiefs and Committee Chairs and members in carrying out their assigned responsibilities.
• Maintains financial records of Medical Staff application and reapplication funds.
• Ensures supporting documentation (agenda, minutes, credentials reports, etc.) for medical staff meetings.
• Processes follow-up requirements as necessary to facilitate effective Medical Staff activity documentation and communication per established policy.
• Facilitates Medical Staff Governance of disruptive behavior and monitoring of active medical issues of medical staff members.
• Facilitates Department review of FPPE, OPPE, and quality metrics of department/members.
• Develops, in conjunction with department chiefs, credentials committee chair, and administrative leadership, physician privileges of new or evolving clinical practices 
• Ensures administrative support of all Medical Staff Department and Committee meetings which includes: preparation of the agenda, recording minutes, initiating and/or providing follow-up actions as appropriate and all other support functions for meetings, i.e., meeting room schedules, AV equipment, dietary, follow-up activities.    

• Works with The Center for Quality Outcomes to provide the department chiefs and committee chairman with performance improvement reports and data for presentations and other activities.
• Coordinates and provides administrative support to the Medical Staff/Affiliated Professional Staff in initial credentialing and privilege delineation activities in accordance with the Medical Staff policies, Bylaws, Rules and Regulations.
• Closely monitors information collection, evaluates adequacy and quality, and pursues additional information if necessary for effective and comprehensive peer review decision-making.
• Coordinates and facilitates both the informal and formal credentialing/peer review    recommendations.
• Works closely with the CMO, Chief of Staff, appropriate department chief and the credentials  committee in the review/recommendation process, including recommendations adverse to the applicant.
• Ensures integrity of all files, electronic and/or hard copy, for members of the Medical Staff and Affiliated Professional Staff. 
• Coordinates maintenance of the Medical Staff credentials software.
• Ensures maintenance of all expirables, i.e., licenses, certifications, insurance.
• Ensures maintenance of demographic information for all practitioners.
• Ensures accuracy of clinical privileging information for all practitioners for use by hospital staff.
• Ensures posting of complete and accurate Medical Staff and Affiliated Professional Staff rosters.
• Maintains personal adherence to professional confidentiality standards, established within the department and in accordance with legal, ethical, and hospital policies.
• Ensures data security and confidentiality.
• Supports the Informatics needs of Medical Staff Members.
• Coordinates security access  and training for Epic system.
• Supports LMConnect eblast.
• Supports Stethoscoop Publications.
• Work closely with the Director, CMO, Chief of Staff and Administration to coordinate the annual Medical Staff Retreat.  Provides all support functions for meetings, i.e., reservations, meeting and function needs, recreation, etc.
• Supports functions of the Health Management Committee.
• Other duties as assigned.