System Director of Medical Staff Affairs and Services

Description:

JOB PURPOSE:
Provides overall strategic direction, management and operational oversight to all Piedmont Healthcare entities regarding the functions of the Medical Staff Office (MSO). Strong understanding of the Medical Staff Bylaws, Medical Staff Rules and Regulations and other medical staff policies. Establishes short and long-term goals that impact the system-wide Medical Staff Office (MSO) Services and procedures in conjunction with the strategic direction of the organization. Works closely with the Central Verification Office (CVO) to ensure files are presented in a timely manner. Provides overall leadership to all Piedmont Healthcare entities to ensure the highest standards are met as it relates to credentialing, privileging, and clinical quality for all credentialed physicians/advanced practice practitioners. Ensures all medical staff policies are updated. Oversees the Medical Executives committee at each entity in conjunction with the System and Entity Chief Medical Officers.

KEY RESPONSIBILITIES:
1. Manages system level compliance with accrediting, legal and regulatory agencies (DNV, CMS, TJC specialty surveys) by serving as a consultant to Administration, Medical Staff leaders and Regulatory Support Team related to Medical Staff standards.
2. Manages the functions of the Medical Staff Office (MSO) Services including approval of credentials by the entity medical staff, granting of appropriate privileges, and other duties of the MSO.
3. Ensures standard application of the Medical Staff Bylaws, Medical Staff Rules and Regulations and other Medical Staff policies.
4. Participates as a subject matter expert in medical staff processes during entity regulatory agency visits, as appropriate.
5. Controls and directs the administrative support of governance documents (i.e., Medical Staff Bylaws, Credentials Policy, Rules and Regulations, and Medical Staff policies, etc.) Ensures that all documents are compliant and current.
6. Protects permanent records by managing a secure record retention process.
7. Assures the sound fiscal operation of the Medical Staff Office (MSO) including monitoring budget variances and staffing levels to achieve budget targets.
8. Works with other quality team members in Quality Reporting and Analytics and Professional Practice Evaluation to design and direct the use of performance improvement data for ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) to make informed decisions regarding practitioner competence both at the time of initial appointment, reappointment, and ongoing throughout the providers appointment to the medical staff. Collaborates with key staff on managing an ongoing reporting process that is accurate, timely and action driven.
9. Ensures Professional Practice Evaluation data is available at the time of credentialing for all providers.
10. Manages processes related to investigative, disciplinary and legal proceedings such as reports to the National Practitioner databank, fair hearing and appeals.
11. Establishes effective working relationships with Medical Staff Leadership, Administration, CMO, Medical Staff Offices, CVO, and the Piedmont Clinic.
12. Works with the MSO staff to coordinate the agendas of the MEC minutes and ensure appropriate information is approved by the entity Boards.
13. Responsible for recruiting, training, mentoring, evaluation and disciplining staff.
KNOWLEDGE, SKILLS, ABILITIES
Skill and ability to communicate effectively both verbally and in writing.
Skill and ability to handle multiple priorities and deadlines.
Ability to work as a member of a team.
Skill and ability in Microsoft Office applications.
Skill and ability in a credentialing database. Cactus experience a plus.
Disclaimer
The above information is intended to describe the general nature and level of work being performed by people assigned to this job. It is not intended to be an exhaustive list of responsibilities, duties and skills required of personnel so classified.

MINIMUM EDUCATION REQUIRED:
Bachelors degree in Business or a related healthcare field.

MINIMUM EXPERIENCE REQUIRED:
Seven (7) years of progressive experience in Medical Staffing Affairs or closely related experience, preferably in an acute care setting, to include three (3) years of leadership experience

ADDITIONAL QUALIFICATIONS:
Masters in related healthcare field preferred.
Certified Professional Medical Services Management (CPMSM) and/or Certified Provider Credentialing Specialist (CPCS) preferred.
Medical staff credentialing and peer review experience preferred.
Multi-campus experience a plus.
Excellent human relations, organizational and communication skills are essential.
Leadership style and characteristics necessary to effectively perform in this role include: strong work ethic, results-oriented; persuasive; motivational; able to make rational decisions in difficult situations; confident; systems-thinker; innovative; life-long learner; high-energy; integrity; ability to work with teams; and passionate about continuously improving and providing high quality care and service excellence to patients, families, employees and physicians.