Coordinates medical staff credentialing functions to assure compliance with federal, state and regulatory agency licensing/regulatory standards. Coordinates Credentials Committee meeting agendas, minutes, and follow-up. Acts as liaison between administration, medical staff leadership, individual applicant and appointee. Establish implement and ensure that Medical Staff credentialing practices and procedures for physician and allied health practitioner that are in accordance with JCAHO, Title 22 and other regulatory agencies and overall hospital policies. Interpret and apply medical staff By-laws, Rules and Regulations; and departmental rules and regulations as they apply to appointments, reappointment, and credentialing functions of established committee. Initiate or assist in initiating proposed bylaw amendments as pertain to these activities. Develop, maintain, and revise delineation of clinical privileges and scope of practice forms. Responsible for verification of all applicants for medical staff appointments as well as those requests received from other institutions pertaining to staff members. Oversee, develop, and maintain credentials data base programs. Assume responsibility for the maintenance of all credential and confidential Peer Review files. Coordinate the Credential Committee and such other committees as assigned including staffing, scheduling, and preparing materials, minutes and notices prior to meetings, documenting proceeding, maintaining records, and follow-up or actions taken. Assist medical staff officers, department directors and other health care professionals in the development of mechanisms to assess physician performance within the context of reappointment and clinical appraisals. Serve as liaison between the medical staff, administration, and ancillary departments in matters pertaining to medical staff credentialing, appointment, reappointment and related Medical Staff activities. Assist Medical Staff Officers and hospital administration in projects as assigned. Assist the Director of Medical Education in the development of the Medical Staff Office goals and budget.
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Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED