Manager Medical Staff Office, Multi-Site

Mountain Region Support•West Jordan, UT

21h•Onsite

About The Position

With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community. You have a purpose, unique talents and now is the time to embrace it, live it and put it to work. We value incredible people with incredible skills – but your commitment to a greater cause is something we value even more. This is the heartbeat of our organization and your time will be spent in a supportive, team environment with resources to help you flourish and leaders who care about your success. 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. Must establish many effective relationships, work within organizational structures and cultures, manage various systems/policies. This position has responsibility for 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. The position plays a key role in physician recruiting and retention, department performance improvement and patient safety initiatives, and 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.

Requirements

Minimum of (5) years of experience in a Medical Staff Services Department
At least one (1) year in a supervisory capacity.
Bachelor’s degree preferred. In lieu of educational requirements previous work history and years of experience may be considered.
Current certification as a NAMSS Certified Provider Credentialing Specialist (CPCS) required, or achieve certification within three and a half years of employment.

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.
Establishes effective relationships, works within organizational structures and cultures, and manages various systems/policies.
Ensures compliance with all TJC, DNV, CMS, Department of Health and licensure standards, and numerous state and federal peer review laws.
Meets 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.