Director, Medical Staff Services

Wellstar · Kennestone Hospital

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How would you like to work in a place where your contributions and ideas are valued? A place where you can serve with compassion, pursue excellence and honor every voice? At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

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Job Summary:

The Director, Medical Staff Services supports the Medical Staff organization including the Department and Committee structure; the credentialing, recredentialing, and privileging process; provides assistance to the Medical Directors and Medical Staff Leadership and many other diverse functions. The Director of Medical Staff Services provides guidance, direction and leadership in all areas of Medical Staff Services support, system credentials process, and to the Medical Directors and Medical Staff Leadership in a hospital.

The position provides management support to the hospital Medical Staff and its functions and maintains responsibility for monitoring all applicable regulatory laws and statutes (state and federal) and accreditation standards as well as WellStar Health System and Medical Staff Bylaws, Rules & Regulations and Policies & Procedures for compliance by the Medical Staff organization. These include, but are not limited to, State, CMS, FDA, and Joint Commission on Accreditation of Healthcare Organizations This position directs the daily operations of Medical Staff Services and oversees the personnel within the department for effective support of the Medical Staff organization and its leaders.

Director is responsible for Department financial accountability, management development, human resources issues, and customer service strategies.

Core Responsibilities and Essential Functions:

Medical Staff/Support Functions: Provide to facility quality support by qualified Medical Staff Services professionals who are trained to support the multiple functions specific to the Medical Staff organization. Establish the Medical Staff Services Office as an in-house resource, liaison, and partner for the Medical Staff Leaders in the facility.

• a. Oversees support of Medical Executive Committee, Departments, and Medical Staff Committee for a Hospital which requires:
• b. Monthly calendars, meeting notices, room reservations, dietary orders, attendance rosters
• c. Development of meeting agendas and meeting information packets
• d. Maintaining accurate minutes of meetings
• e. Ensure appropriate and expeditious follow-up on committee/department actions
• f. Maintain minute books of all committees and departments
• g. Responsible for Corrective Action support, including Fair Hearing process which requires:
• h. Interviewing/Counseling
• i. Development of Action Plans
• j. Support of Fair Hearing Process per Policy
• k. Functions as Resource/Guidance for Medical Staff Leadership, Medical Staff in general, Medical Directors, and Administrators/Senior Leadership
• l. Functions as liaison between Medical Staff and Administration/Senior Leadership
• m. Oversight of Medical Staff, Allied Health, and Leadership Orientation/Education/Development
• n. Responsible for submission of monthly reports to WellStar Medical Affairs Committee and WellStar Governing Body including any new or revised documents including, but not limited to Medical Staff Bylaws, Rules & Regulations, Policies & Procedures, privileging criteria and forms, etc.

Credentials Functions: Provide high-quality, single-application process for Medical Staff Membership and Allied Health Professionals in a timely, cost-effective manner.

• a. Oversight of credentialing/privileging for Medical Staff for a Hospital, Physician Group, PHO, and delegated credentialing for managed care organizations for all appointments and reappointments.
• b. Oversight of credentialing/clinical functions for Allied Health Professionals for a Hospital and Physician Group.
• c. Assure appointment and reappointment process initiated and completed per policy, JCAHO standards, and state/federal regulations.
• d. Analytical responsibility for credentialing information obtained during application/reappointment process.
• e. Responsible for maintenance of current, individual credential file for each Medical Staff Member and Allied Health Professional.
• f. Assures appropriate interface with Quality Improvement and Risk Management regarding credentialing/ privileging assessments and issues.
• g. Oversight of communication with all applicants regarding membership and privileging.
• h. Oversees processing of emergency Non-Staff Temporary privileges, processing of locum tenens privileges, processing of students/residents, credentialing of Hospice applicants, and disaster privileging.
• i. Oversees development and maintenance of current credentialing database.
• j. Responsible for setting up/educating users of credentialing software.
• k. Responsible for physician master file in Star Patient Care System.
• l. Responsible for submission of monthly Credential Reports to WellStar Medical Affairs Committee and WellStar Governing Body.

Regulatory Compliance/Continuous Survey Readiness: Maintains current working knowledge of all regulations, statutes, laws and accreditation standards that regulate the organized medical staff and the credentialing process. Provide guidance and serve as expert resource to the Medical Staff Leadership and organization in these areas. Identify the need for amendments to documents such as Medical Staff Bylaws, Policies or Rules and Regulations when required to maintain compliance.

• a. Responsible for compliance with all appropriate regulatory body standards, state requirements and procedures.
• b. Demonstrates accurate knowledge of internal Medical Staff Bylaws, Rules and Regulations, and Policies and Procedures.
• c. Demonstrates accurate knowledge of external accrediting standards as well as state and federal regulatory requirements.
• d. Provides Medical Staff and Administration/Senior Leadership with appropriate interpretation of standards and regulatory requirements.
• e. Coordinates and participates in development and revision of documents to ensure compliance.
• f. Assures Medical Staff compliance to internal and external regulations and standards.
• g. Communicates needed modifications in Medical Staff Bylaws, Rules & Regulations and Policies and Procedures to Administration/Senior Leadership and Medical Staff Leadership.
• h. Develop and modify Medical Staff Bylaws, Rules & Regulations, Policies & Procedures, and/or forms as appropriate to reflect compliance.
• i. Oversight of development and distribution of monthly emergency call rosters per EMTALA regulations.
• j. Interpret latest recommendations of JCAHO standards in reference to Medical Staff and credentialing/ privileging.
• k. Responsible for maintenance of all required Medical Staff organization documents, minutes, files, etc.
• l. Responsible for Medical Staff Services preparation and participation in surveys conducted by JCAHO, CMS, FDA, State, etc.
• m. Serve as liaison between Medical Staff and Hospital Attorney on medico-legal issues as needed.

Management/Staff Development: Creates and maintains a positive work environment. Develop, support, and encourage educational opportunities (formal and informal) for Medical Staff Services professionals, Medical Staff leaders, and credentialing personnel in order to promote quality leadership and support services.

• a. Collaborate with Senior Leadership to define the goals and objectives of the Medical Staff Services Department ensuring alignment with Hospital and System strategic goals.
• b. Provide staff with clear expectations, goals, directions and identify areas of opportunity for improvement.
• c. Oversight of personnel management from recruitment to employee development.
• d. Interview, hire and orient staff for direct report positions.
• e. Oversight of Medical Staff Services job performance standards.
• f. Oversee/assist in performance evaluations. Complete performance evaluations for direct reports.
• g. Responsible for evaluation of departmental structure, reporting relationships and staff.
• h. Responsible for evaluation of workload, promoting optimal productivity.
• i. Oversight of cross-training and education of employees.
• j. Support ongoing education and leadership development of management staff.
• k. Responsible for identifying customer service needs, improving, and meeting customer expectations.
• l. Conduct regular Department meetings and in-services.
• m. Oversee resolution of staffing issues, counseling of personnel, and following grievance procedures when warranted.

Communication: Serve as liaison between Medical Staff, Administration, Senior Leadership and other Departments. Assures customer service by the Medical Staff Services office. Improve and promote communication and teamwork among the various Medical Staff Organizations as well as within the Departments and between Medical Staff Services and the Medical Staff Leadership, Administration, Senior Leadership and other related Departments. Foster team approach between departments in the communication of information related to credentialing, quality improvement, risk management, and other pertinent support functions.

• a. Maintains excellent working relationship with Medical Staff Leaders and other Medical Staff Members.
• b. Maintains excellent communication with Administration, Senior Leadership and other relevant Departments.
• c. Assists Medical Staff Members when requested.
• d. Responsible for reports to the Medical Staff, Administration, Senior Leadership and other Departments as required.
• e. Provide oversight for the content, ongoing development, and management of the Medical Staff Services Web Page as a means to effectively communicate key information to Medical Staff Leadership, Medical Staff Members, Allied Health Professionals, Medical Directors, Senior Leadership, Administration, and Hospital Departments.

Financial Responsibility: Maintains fiscal responsibility accountability for Medical Staff Services and assists with an annual budget.

• a. Develop/coordinate preparation of both Operating and Capital Budgets.
• b. Oversight and management of budget evaluations, submission of variance reports and action planning to address areas for immediate attention.
• c. Oversee and/or implement new or revised programs.

Performs other duties as assigned
Complies with all WellStar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

• Bachelors Business Administration/Management or Bachelors Health Administration

• Additional years of relevant work experience and/or other specialized training can be used to lieu of minimum education requirement.

Required Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

Required Minimum Experience:

• Minimum 5 years of leadership experience as a medical staff services professional within a hospital setting, with increased levels of responsibility, to include supervisory experience. (Required)

• Must have documented experience with multiple medical staff departments and committees and supervisory responsibility for three or more support staff. (Required)

• Experience with one or more Joint Commission surveys including the preparation of medical staff for interview and file review components of the survey and attendance/participation in previous survey is a requirement. (Required)

• Experience using medical staff database technology required and must support optimal use of the database. (Required)

Required Minimum Skills:

• Must have working knowledge of medical staff credentialing/privileging process and comprehensive knowledge base of state/federal regulatory requirements and accreditation standards related to the organized medical staff.
• Must have a working knowledge of all areas of medical staff governance, including practitioner credentialing and privileging processes and the applicable Joint Commission standards that address medical staff organizational requirements.
• Must have knowledge of current federal and state laws and regulations relevant to medical staff functions and have the ability to draft needed revisions to documents required for compliance.
• Must demonstrate personal attributes and behavior that contributes to a climate of excellence.
• Demonstrates ability to lead, manage, and/or effect change and interacts effectively with the Medical Staff Leadership, Medical Staff in general, Medical Directors, Administration, Senior Leadership, external agencies, hospital attorneys, and WellStar Health System/Hospitals leadership/departments for increased communication and effective decision making relative to the Medical Staffs responsibilities and needs.
• Must demonstrate the ability to use discretion and independent judgment when problem solving or assisting leadership in decision-making processes and must maintain confidentiality in all aspects of medical staff and peer review information.
• Must be able to effectively multitask, prioritize, delegate, organize and meet deadlines established and agreed upon for optimal results as defined.
• Must be able to adapt to a flexible work schedule with frequent interruptions, possess strong communication and people skills, have the ability to motivate and lead, and perform duties and responsibilities promptly and consistently with little direct supervision.
• Excellent problem-solving skills with the ability to judge the appropriate action in response to changes, circumstances or problems is required as well as the ability to effectively communicate through written material and oral presentations to groups or individuals, using computer enhancements as needed or desired.
• Must have a working knowledge of business operations, including database management and related software programs (Medical Staff Line/Echo, Microsoft Word, Excel, PowerPoint), standard office equipment, business principles and practices, and report writing is required.
• Must have the ability to carry out a varied range of administrative functions: organize, assign, direct and objectively appraise and analyze the job performance of others; maintain an effective work pace under routine and periodic deadlines;
• learn and apply pertinent statutory provisions, rules, regulations, policies, and procedures; create action plans for special projects and manage the implementation process through completion of projects.

Join us and discover the support to do more meaningful work—and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.

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