Job Information
St. Peters Health Medical Staff Services Officer - 1.0 FTE in Helena, Montana
JOB SUMMARY: The Medical Staff Services Officer (MSSO) reports directly to the Chief Medical Officer. The MSSO leads the Office of Medical Staff Services to accomplish all functions associated with the Credentialing and Privileging of providers at St. Peter’s Health and all special services offered to the Medical Staff by the organization to create an exceptional experience for providers. The MSSO is responsible for ensuring the governance of the medical staff is managed compliantly through scheduling of all department meetings and completing minutes for those meetings, and guiding the processes involved in a well-governed medical staff. The MSSO leads the Office of Medical Staff Services team to function effectively and collaboratively to accomplish all the duties of the department. The MSSO facilitates the flow of information from Medical Staff Departments and Committees through the Medical Executive Committee and the Board of Trustees, assists with accreditation survey preparation for the Medical Staff/Leadership function, and works closely with Medical Staff Leaders and Hospital Administration with regard to Medical and Allied Health staff issues. The MSSO coordinates process improvement activities to impact the efficiency and effectiveness of all aspects of the position.
The professional in this job is responsible for:
MEDICAL STAFF CREDENTILING, PRIVILEGING
Schedule, plan, and lead credentialing efforts to meet the needs of the organization. Work with Physician Recruiter to identify potential recruits and ensure they meet qualifications to be members of the active medical staff
Work closely with Chief of Staff and Chair of Credentials to ensure medical staff policy is followed in regards to credentialing
Onboard new providers effectively
Maintains credential files for all members of the Medical Staff & Allied Health Professional Staff in an organized and secure manner
Carries out the appointment and reappointment process as outlined in the Medical Staff Bylaws and in accordance with DNV-GL and CMS standards
Monitor and revise credentialing and privileging policies and procedures and work with Medical Staff Leadership for approval and ongoing review
Processes, through the appropriate Medical Staff Department, all requests for additions/deletions of clinical privileges
Assist Medical Staff Leaders in development of new privileging criteria
Compiles individual practitioner profiles for use at reappointment to include biographical data, participation in medical staff activities/required meetings, QI data and peer review
Compiles letters for the COS to sign notifying practitioners of their appointment, granting of additional privileges, reappointment and/or advancement to the Medical Staff or Allied Health Professional Staff, and the privileges granted
Coordinates timely communication among Medical Staff officers, administrative staff and Board of Directors regarding status of applications and reapplications
Coordinates all portions of the proctoring process including facilitating proctor assignment with department chairs, periodic assessments, peer review and notification of advancement
Ensures all current provider privileges/scope of activities are available for viewing by the appropriate departments in the organization
MEDICAL STAFF COMMITTEE/DEPARTMENT MEETING COORDINATION
Prepares agendas, minutes, and announcements for Medical Staff Department and Committee meetings, and ensures the appropriate follow up is completed
Coordinates meeting room space and food reservations for meetings
COMMUNICATION COORDINATION
Oversees the maintenance of current and accurate Medical/Allied Health Staff databases
Maintains “Unassigned Patient List” for designated providers
Maintains the current list of St. Peter’s Medical Staff & Allied Health Professional Staff mailing lists, circulating as appropriate
Creates, maintains and publishes electronic files such as reports, meeting documents and miscellaneous correspondence
In coordination with IS and according to appropriate corporate compliance policies, authorizes the permissions and access of the medical staff website
Improve and promotes communication strategies and teamwork among the various Medical Staff Departments and between Medical Staff Leadership
MEDICAL STAFF SERVICES OFFICE FUNCTIONS
Maintain primary responsibilities for the direction and coordination of all medical staff support services, monitoring functions, credentialing, re-credentialing, privileging, peer review, ongoing professional practice evaluations and medical education
Effectively manage and achieve ongoing quality and efficiency, as well as identifying opportunities to improve processes and systems
Oversee the daily operations of the Office of Medical Staff Services and direct the work of the Office of Medical Staff Services personnel
Lead, develop, trains and mentor staff to fulfill their position responsibilities and ensure service excellence and creates a work environment that encourages retention and development of staff
Oversee medical staff service professionals providing support and services to the medical staff organization ensuring continuity in services, elimination of redundancy, and consistent documents, policies and procedures
Oversee the planning, implementation, execution and evaluation of special projects requested by CMO, Chief of Staff and Credentialing Chair
Lead and further develop the Physician Support Program
Ensure Medical Staff lounge is adequately stocked and arranged for an exceptional experience for our medical staff
Management of cost/expense and budgeting functions for the Office of Medical Staff Services
Management of direct reports including timecards, evaluations, performance assessments, etc.
Coordinate and maintain Medical Staff bank accounts; collects dues; makes deposits; prepares monthly and quarterly reports for Staff Treasurer
Collaborate with leadership in the planning of physician events and physician surveys
Develop and enhances processes to better facilitate communication, workload and outcome. Develop and manage information systems and reporting to guide strategic decisions related to provider alignment and support
Arbitrate issues between physicians and the hospital that are confidential, sensitive and controversial and escalates to Medical Staff Leadership as appropriate
Assists with problem resolution for Medical Staff and Department
Lead, analyze, and interpret general business periodicals, professional journals, technical procedures and governmental regulations to maintain quality of guidelines in use
Directs Medical Staff in the conduct of all disciplinary corrective actions, hearings, and appeals to the Hospital Authority
Interprets, explains and follows all regulatory guidelines, including medical staff bylaws, fair hearing plan, rules and regulations and policies
Consult and assist with legal counsel, hospital and medical staff leadership to ensure compliance with substantive and procedural due process requirements applicable to Federal/State Laws, Medical Staff Bylaws, Rules and Regulations and other applicable policies and procedures
Guide the Medical Staff in concert with legal counsel, through disciplinary processes involving physicians and allied health professionals. Maintains the official record of all proceedings
Serve in advisory capacity to hospital and medical staff leaders related to defined areas of responsibility
Assists Medical Staff and Leadership with corrective actions, summary suspensions, and the hearing and appellate review processes when necessary
Directs and manages new Physician Orientation activities, coordinate new physician orientation, oversee revision and publication of orientation manual as needed
Development of training and orientation materials for the new Medical and Allied Health Staff appointees
Manage and assist in negotiating the delegated credentialing agreements, ensure agreements are executed and that contract terms are summarized for monitoring purposes
Lead the performance of delegated credentialing audits in collaboration with designated credentialing staff to ensure all practitioner files meet delegation criteria
Actively maintains Medical Staff governance documents (Bylaws, Rules and Regulations, Department Rules and Regulations)
Coordinates and maintains MSO "governance documents" such as medical staff bylaws, rules and regulations, related documents (organization and functions manual, credentials policy, etc.), and policies and procedures of the MSO. Assures that there is review of existing policies and governance documents on a regular basis and recommends changes to the MEC as appropriate
Develop and implement hospital and medical staff policies and processes to reflect best practices and assure compliance with standards, laws and regulations
Maintains knowledge of standards of the DNV-GL and CMS, and State and Federal regulations related to Medical Staff organization. Assists the Medical Staff to maintain compliance with regulation and standards
Maintains working knowledge of the Medical Staff Bylaws and Policies, and Hospital policies, and assists with the Medical Staff’s compliance with the stated parameters
Develops action plans in accordance with recommendations received by DNV-GL and CMS, Quality/Risk Management, Legal, and Federal or State Regulators, Coordinate with Peer Review Specialist to ensure physician reporting (e.g., Focused Assessments and Continuous Assessments) is conducted according to regulatory and accreditation requirements
Oversee and participate with the implementation of credentialing software; includes continuously reviewing and updating training materials and resource guides, working with the vendor for new measure development and reporting capabilities to meet the needs of the facilities as well as regulatory and accreditation requirements
Serve as the credentialing software resource for facility by providing education to all end-users (MSS Department, providers, department chairs and CMO)
Coordinate the medical staff performance improvement/peer review functions, ensuring findings are appropriately reviewed, communicated and documented
Coordinate continuing medical education programs for the medical staff and ensure compliance with CME accreditation process
Development of policies and procedures for the Office of Medical Staff Services
Oversee management of physician on-call schedule
Has authority to hire and fire within the Office of Medical staff Services
Assumes other related responsibilities as the need arises
JOB RELATIONSHIPS: Reports directly to the CMO. Workers supervised: All FTEs in the Medical Staff Services Office. Interrelationships: Medical Staff Leadership, Medical Directors, Medical/Allied Health Staff, Hospital Administration, and Hospital Leadership, Quality, Safety and Accreditation teams.
QUALIFICATIONS, KNOWLEDGE AND EXPERIENCE:
Experience: 3 years healthcare experience required, preferably in a medical staff service-related position. Experience with Healthcare Credentialing and Privileging function is required.
Education: Bachelor’s degree required. Medical Administrative Support training or job experience and minute taking experience required
Leadership: Leadership and management skills are essential for success in this position.
Licensures, Certifications, Registrations: Certification for Professional Medical Services Management (CPMSM) and expected to complete within 5 years of starting or Certified Provider Credentialing Specialists (CPCS) and expected to complete within 3 years of starting
JOB KNOWLEDGE/APTITUES:
A professional demeanor and regard for privacy and confidentiality of sensitive information
Excellent interpersonal skills, including the ability to communicate professionally, both verbally and in writing.
Solid knowledge of DNV-GL standards as they relate to the Medical Staff.
Excellent organizational and analytical skills, ability to make independent decisions, ability to carry out detailed instructions, work well with little supervision, meet deadlines, and ability to coordinate multiple projects simultaneously.
Computer literate, with strong proficiency in MS Word, Access, Excel, PowerPoint, and Internet use.
Excellent customer service approach to interacting empathetically with internal and external customers.
Cognitive and emotional abilities to deal effectively with multiple stressors, deadlines, and customer needs.
Self-starter, with initiative and awareness of surroundings and willingness to work as part of a team
Goal directed and persistent, yet innovative in approach to completion of tasks
7145.729