Manager Medical Staff Office, Multi-Site

CommonSpirit Health•West Jordan, UT

3d•Onsite

About The Position

CommonSpirit is a healthcare organization with over 700 care sites across the U.S., including clinics, hospitals, home-based care, and virtual care services. They are committed to building healthy communities, advocating for the poor and vulnerable, and innovating healing. This role provides leadership and oversight for all aspects of Medical Staff governance, including credentialing, peer review, medical staff relations, and management of the Medical Staff Services Department. The position requires establishing effective relationships, working within organizational structures, and managing systems and policies. It ensures compliance with TJC, DNV, CMS, Department of Health standards, and state and federal peer review laws. The role is crucial for physician recruiting and retention, department performance improvement, patient safety initiatives, and serves as a liaison between Medical Staff, Administration, and Boards. The Manager acts as the primary liaison for the hospital CMO, physicians, Medical Staff officers, department chairpersons, administration, and hospital staff for the Medical Staff department. They ensure appropriate information flow between departments, committees, administration, Medical Executive Committees, and the Board of Trustees, and coordinate dissemination of information to physicians and hospital departments. The role also involves resolving physician satisfaction concerns, problem-solving operational and governance issues, and managing the initial application and reappointment process for Medical Staff and APP. Additionally, the Manager assists with budget preparation, monitors privileging criteria approval, and develops/implements improvements for professional practice reviews, potentially directing peer review activities and interfacing with the Quality Department. This is an on-site position, Monday - Friday.

Requirements

Minimum of (5) years of experience in a Medical Staff Services Department
At least one (1) year in a supervisory capacity
Current certification as a NAMSS Certified Provider Credentialing Specialist (CPCS) required, or achieve certification within three and a half years of employment.

Nice To Haves

Bachelor’s degree preferred.
In lieu of educational requirements previous work history and years of experience may be considered.

Responsibilities

Provides leadership and oversight of all aspects of Medical Staff governance to include credentialing, peer review, medical staff relations, medical staff meetings, and management of the Medical Staff Services Department.
Ensures compliance with all TJC, DNV, CMS, Department of Health and licensure standards, and numerous state and federal peer review laws.
Responsible for meeting all reporting requirements appropriately for the licensing entities, DOH, CMS, and NPDB at the applicable facility.
Plays a key role in physician recruiting and retention, department performance improvement and patient safety initiatives.
Serves as an essential link between the various Medical Staff, Administration and Boards with the coordination of information flow.
Serves as primary liaison for the hospital CMO, physicians, Medical Staff officers and department chairpersons, administration, and hospital staff for the Medical Staff department.
Ensures correspondence flows of appropriate information through various facility departments, committees, administration, Medical Executive Committees, and Board of Trustees.
Formulates and monitors the information flow to the hospital’s Board of Trustees regarding Medical Staff actions and recommendations.
Coordinates the dissemination of information to individual physicians, Medical Staff leadership and hospital departments to ensure smooth operations at the hospital.
Resolves physician satisfaction concerns in a timely manner, assuring they have been thoroughly addressed.
Problem solves and corrects day-to-day operational and governance issues and reports to management at the hospital.
Manages and oversees the effective functioning of the Medical Staff and APP initial application and reappointment process in compliance with accreditation standards, Medical Staff Bylaws, credentials policies, rules and regulations.
Assists with preparing the department budget, including personnel, space allocation and resources necessary to provide designed services.
Monitors and facilitates the approval process of each Medical Staff's recommendations regarding privileging criteria/qualifications and ensures the consistent application of such criteria.
Develops, implements and recommends improvements to both focused and ongoing professional practice reviews to ensure compliant and effective peer review at the hospital.
May direct Medical Staff peer review activities, ensuring both accreditation/legal compliance and risk-management effectiveness for the hospital.
Interfaces with the facility's Quality Department to integrate and coordinate actions appropriately.