Responsible for facilitation of all Medical Staff functions. Leads the credentialing and privileging processes, including critically analyzing practitioners’ data to create informed recommendations for Medical Staff leaders and committees. Participates in quality assessment and improvement activities of the Medical Staff, including peer review, Focused Professional Practice Evaluation (FPPE), Ongoing Professional Practice Evaluation (OPPE), and corrective actions. Ensures continuous adherence to regulatory requirements, accreditation standards, Medical Staff Bylaws, Medical Staff Rules and Regulations and Medical Staff and organizational policies and procedures.

Major Responsibilities:

Coordinates and facilitates medical staff and advanced practice professional credentialing and privileging at the time of initial appointment and biennial reappointment. Critically analyzes data to create informed recommendations for credentialing, re-credentialing, and privileging for Medical Staff leaders and committees, ensuring adherence to accreditation standards, state and federal law, and Medical Staff bylaws. Verify and analyze practitioner-specific data obtained during the credentialing and privileging for approval bodies. Identify, review and report practitioner performance data, complaints, sanctions, adverse actions, and quality of care issues in order to facilitate analysis and evaluation of current/ongoing practitioner competency by approval bodies, including Credentials Committee, Medical Executive Committee, and Governing Bodies.Ensures continuous knowledge of and adherence to regulatory requirements, accreditation standards, Medical Staff Bylaws and Medical Staff and organizational policies and procedures. Ensures all practices and procedures are in accordance with Det Norske Veritas (DNV), The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), Healthcare Facilities Accreditation Program (HFAP), Emergency Medical Treatment and Labor Act (EMTALA), Healthcare Quality Improvement Act (HQIA), National Committee for Quality Assurance (NCQA), Utilization Review Accreditation Commission (URAC), State law, Medical Staff bylaws and hospital and system-wide policies. Responsible for coordination of and survey preparation for all Medical Staff matters for regulatory surveys and audits. Reviews and implements new actions related to federal and state rulings and accrediting body standards pertaining to the functions of the Medical Staff.Develops, establishes, and enforces Medical Staff bylaws, rules and regulations, and policies that govern the activities of the Medical Staff and coordinates the activities of the self-governing organized Medical Staff.Coordinates and manages the onboarding and orientation of newly appointed practitioners to the Medical Staff, including development, implementation, and maintenance of the regulatory and legally required education. Ensures accurate entry of privileges, arranges authorization processes to allow practitioners electronic medical record access, makes all appropriate entries into applicable systems to activate the practitioner and ensure practitioner inclusion in rosters, directories, and reports.Responsible for creating monthly reports for the Governing Bodies on credentialing and privileging, and other Medical Staff actions and matters.Collaborates with the quality management department to develop and distribute quality data for the Focused Professional Practice Evaluation (FPPE) process and the Ongoing Professional Practice Evaluation (OPPE) according to regulatory requirements. Researches and recommends FPPE criteria and ensures that all new applicants undergo FPPE within established timeframes, following up with proctors and/or reviewers as necessary. Collaborates with Department Chiefs and Section Chairs to review OPPE data.Serves as a liaison between the medical staff, administration, ancillary departments and patients.Establish and maintain systems to facilitate committee meetings and communication for the Medical Staff governance structure, adhering to Robert’s Rules of Order, including with Medical Staff leaders and members, departments and sections, and hospital administration.

Licensure, Registration, and/or Certification Required:

None Required.

Education Required:

High School Graduate.

Experience Required:

Typically requires 3 years of experience in a health care setting that includes experiences in privileging and credentialing processes.

Knowledge, Skills & Abilities Required:

Maintain upward communication with leadership regarding development within areas of assigned responsibilities and perform special projects as required or requested.Ability to represent the department effectively with supporting teams.Demonstrate problem solving, critical thinking, and process analysis skills to support teams.Possess willingness to learn and develop understanding of configuration best practices.Willingness to escalate issues that may impact team productivity or confusion on priorities.Strong knowledge of medical terminology.Excellent communication, organizational and problem solving skills.Must have proven track record of effective interactions with physicians and other health care professionals.Proficient in the use of Microsoft Office (Excel, Access, PowerPoint and Word) or similar products.Ability to work effectively with minimal supervision and manage multiple priorities.

Physical Requirements and Working Conditions:

Must be able to sit for extended periods of time.Must be able to occasionally lift up to 10 lbs.Must be able to use hands with fine manipulation when using keyboard.Must hold a valid driver's license and be willing to travel between Metro Region Hospitals as needed.Exposed to a normal office environment.Operates all equipment necessary to perform the duties of the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.