Position Purpose

The Manager oversees all activities for which the Medical Staff Department is involved with, and responsible for supervisory and administrative work in directing and coordinating the Medical Staff Services Department. This role is responsible for the coordination of all operational aspects of the department, including organizing and conducting programs and establishing procedures for medical staff functions.

The Manager serves as a liaison between the Hospital and Medical Staff for purposes of communicating requirements of the Hospital to the Medical Staff (and vice versa) and in keeping the Medical Staff apprised of legal requirements and current Medical Staff issues. This position manages all activities associated with accrediting agencies as applicable to the functions and services of the department.

Nature and Scope

This position continues to meet considerable challenge in keeping up with increasing regulation in the area of physician relationships. Responsibilities include:

Organizes and directs the Medical Staff Office to assure continued accreditation by the Joint Commission on Accreditation of Healthcare Organization (JCAHO) and other regulatory organizations.

Interprets, explains and follows all regulatory guidelines, including medical staff bylaws, fair hearing plan, rules and regulations and polices.

Maintains systems to identify (and disseminate to others) medical staff members and their clinical privileges, prepares and maintains other related records and reports.

Updates and maintains systems (physician privileges, medical staff roster, Medical Staff Bylaws, etc.)

Works with the CVO to ensure the proper credentialing for physicians, allied health professionals, and other health professionals/categories specified in the Medical Staff Bylaws. Works with medical staff leadership and hospital clinical staff for the approval and ongoing review of these practitioners.

Oversees the function of coordinating residents, medical students, and fellowships.

Coordinates new physician orientation. Oversees revision and publication of orientation manual as needed.

In conjunction with the CMO, oversees the medical staff performance improvement/peer review functions, ensuring findings are appropriately reviewed, communicated and documented.

Assures the ongoing development and implementation of policies and procedures that guide and support the provision of services.

Evaluates effectiveness of all Medical Staff department programs, analyzes trends and implements changes as required.

Oversees the daily operations of the Medical Staff Services department and directs the work of the Medical Staff Services department personnel. Directly responsible for all personnel actions including, but not limited to, hiring, performance appraisals, promotions, orientation, vacation schedules, maintaining payroll records and time reports.

Directly responsible for the preparation of department budget. Make budgetary recommendations and projections. Monitor, verify and reconcile expenditures of budgeted funds, compiling information reflecting expenditures, and develop cost-comparisons. Identify cost savings within the operation.

This position does not provide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications
Requirements - Required and/or Preferred

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. Bachelors degree preferred.

Experience:

Experience in physician relations and interaction is required. Five years administrative or supervisory experience in health care related area required.

License(s):

None

Certification(s):

Desired (not required): Certification in NAMSS, CPMCM or CPCS.

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.