Executive Director Medical Staff Affairs

at  Providence

QUALIFICATIONS

• Bachelor’s Degree.
• Attendance of related professional seminars and educational events to provide the knowledge described in Job Specific KSAs section.
• Upon hire: NAMSS (National Association Medical Staff Services) leadership certification.
• Upon hire: NAMSS (National Association Medical Staff Services), Certified Professional Credentialing Specialist (CPCS) certification.
• Upon hire: HealthCare Quality and Peer Review training.
• Upon hire: NAMSS (National Association Medical Staff Services), Certified Professional Medical Services Management (CPMSM) (preferred).
• 10 or more years of experience in field of medical staff services and credentialing systems.
• 8 years of experience in progressive leadership and management roles.
• Oral and written communication skills.
• Interpersonal skills.
• Strong management and leadership abilities.
• Independent problem solving and analytical skills.
• Decision making and negotiating skills.
• Knowledge of the medical staff organization responsibilities and its related bylaws and rules/regulations.
• Knowledge of current TJC (The Joint Commission), CMS, CDPH, title 22, MBC, ACCME, and other regulatory standards.
• Create a culture of high reliability and consistent utilization of HRO tools within the departments.
• Knowledge of information systems and data management techniques.
• Ability to work well under pressure and to remain calm in stressful situations.

THE ROLE

The Executive Director Medical Staff Affairs is responsible for the strategic and administrative direction of all medical staff services functions including credentialing, re-credentialing, medical staff bylaws and rules/regulations development and revision for the South Division. Provides strategic direction for continuing medical education including meeting all Federal and State requirements across the South Division, planning activities and conferences that further the education and quality of the physicians in the division. Responsible for division operations, budgeting, planning, development of information systems and coordination of information flow within the service areas across the division and the medical and allied health departments. This position will also collaborate with the North and Central Division MSO leaders and the Medical Staff Office Governance Committee to ensure compliance with system-related initiatives that reduce variation among the medical staff offices.

ESSENTIAL FUNCTIONS

• Ensures a successful streamlined process for initial appointments and reappointments throughout all of the South Division ministries and lead move to single credentialing and peer review software platform.
• Provides guidance and support to the medical staff for grievance procedures and the fair hearing process in accordance with the medical staff bylaws and the rules and regulations and works with legal counsel as needed.
• Serves as a resource for and promotes compliance with regulatory standards related to all South Division medical staff offices and supports external regulatory surveys as applicable.
• Coordinates, streamlines and continually enhances South Division Medical Staff Communications across various media platforms.
• Represent the South Division as a subject matter expert in the Medical Staff Office Governance Committee and collaborate across the enterprise with an overarching goal to modernize, integrate and standardize the functions connected to the MSO with a collaborative, innovative and “best practice” approach.
• Standardizes and oversees divisional onboarding and mandatory education for Providers, Observers and Students.
• Assists the Medical Staff in review and revision of Medical Staff bylaws and the rules and regulations as needed to accommodate regulatory changes and to facilitate functional improvement.
• Supervises and optimizes Central Verification Office (CVO) function with intention to disseminate throughout Division.
• Develop and supervise the annual budget of the medical staff offices across the South Division.
• Provides oversight of Physician Call Schedule compilation and dissemination system and processes.
• Will be responsible to ensure best practices in peer review processes in each ministry and migration to single peer review software platform.
• Provides oversight for Ongoing Professional Practice Evaluation (OPPE) helping to support early detection and response to performance issues that could negatively impact patient outcomes. Also, provides oversight to Focused Professional Practice Evaluation (FPPE) processes ensuring process are in place to effectively evaluate the privilege-specific competence of practitioners. Leads migration to uniform OPPE platform and process to support physician performance evaluation.
• Responsible for all identified outcome measures as denoted on Performance evaluation.