Medical Staff Credentialing Coordinator

Job Description Summary

The Medical Staff Credentialing Coordinator requires a high degree of confidentiality and critical decision-making. Requires moderate direction and guidance. Has complex relationships with members of the administrative staff of the hospital, members of the Medical Staff and Advanced Practice Staff, Medical Staff Executive leadership, legal counsel, Medical Staff professionals at other facilities, state licensing bodies, other departmental personnel and patients. All require courtesy, tact, patience, cooperation and confidentiality.This position provides highly skilled coordination and maintenance of, in accordance with State, Federal, and TJC accreditation, provider credentialing and privileging. Coordinates administrative and clerical tasks; medico-legal issues; maintains of critical and confidential credentialing, privileging, and peer review information; executive correspondence; ongoing-professional performance evaluations (OPPE); and focused professional performance evaluations (FPPE).

Job Description

1. Routinely handles highly sensitive and confidential information.
a. Consistently maintains confidentiality of department information as observed by Manager.

2. a. Initiates credentialing processes and procedures in accordance with the timeframes established within the Bylaws, organization credentialing plan, and within a sufficient timeframe to ensure best-evidenced based practice in credentialing and compliance with TJC requirements.

b. Coordinates and maintains all processing of all aspects of physician and advanced practice practitioners credentialing processes within appropriate timeframes ensuring the quality of the practitioners providing patient care.

Assures the completeness and accurateness of the credentialing process in accordance with TJC, CMS and State requirements and best evidenced based practice. Requests additional information from external and internal sources as needed.

Collects and compiles data for provider profiles to analyze practice patterns using data to determine performance. This includes working with senior staff, determent chairpersons, quality staff, and other hospital staff to identify sources of data and methods of presenting and analyzing data.

c. Is responsible and accountable for the primary source verifications of all aspects of credentialing and privileging in accordance with TJC, State and Federal regulations, organization policies, procedures, and Bylaws and best-evidenced based practice.

d. Understands and maintains an accurate, secure and updated database of provider information to query on basic demographic profiles including but not limited to staff privileges and status for other hospital departments and facilities requiring this information. Uses various internal databased to gather and analyze provider data used in the reappointment, peer review, and quality improvement processes of the Medical Staff and Board of Directors.

e. Obtains necessary privileging documentation and clinical activity for establishment and maintenance of competency requirements as defined by Joint Commission standards and State & Federal regulations. Ability to recognize and question responses to queries and competency requests as recommended by best-evidenced based practice and outlined by the Medical Staff Bylaws/Credentialing Policies and Procedures.

Provides for timely and accurate collection, transmission, analysis and reporting of Center for Medicare / Medicaid Services and The Joint Commission, NPDB, and peer review statutes.

Abstracts clinical data from patient encounters for privileging, OPPE, and FPPE following the rules in the specification manuals for Hospital Quality measures, HIPAA, and peer review statutes.

Understands, is accountable for, and processes focused professional performance evaluations (FPPE) for providers for initial, reappointment, and new and additional privilege requests in accordance with TJC and Federal guidelines and regulations.

Understands, is accountable for, and processes ongoing professional performance evaluations (OPPE) for providers as required throughout a provider's membership in accordance with TJC and Federal guidelines and regulations.

f. Prepares credentialing and privileging, OPPE, and FPPE for review by Credentials Committee, Medical Executive Committee, Chairpersons, Administration according to Medical Staff Services standard to ensure appropriate approval of privileges and staff membership.

Plays a key role in the organization's patient safety initiatives, including practitioner education, development and identification of variations in care.

Works collaboratively with Director, Manager, and key department and individuals in developing strategies and initiatives to improve compliance with medical Staff goals, objectives, and initiatives.

Assists with focus studies, when appropriate, to support Medical Staff quality initiatives and Medical Staff performance improvement activities.

Responsible for ensuring appropriate improvement follow-up occurs and effective collaboration with appropriate owner when needed.

h. Process Medical Staff Resignations as needed.

Process change of status requests as needed.

Process additional privilege requests in accordance with best-evidenced based practice, TJC standards, and State and Federal guidelines.

Assures completeness and accurateness of enrollments of providers in the National Practitioner Databank (NPDB) as required by Federal regulations and TJC. Queries the NPDB as required for initial, reappointment, change in staff status, additional privilege requests, and other instances as required by mandates, policy, and procedure.

Serves as a resource for Medical Staff, APC staff, and organization teams regarding Medical Staff Bylaws, Rules and Regulations, departmental policies and procedures, regulatory requirements, and parliamentary procedure.

Understands, is accountable for, and processes maintenance of Expirables, including, but not limited to MA Licensure, DEA, MA Controlled substance, Malpractice, AMA certifications, and/or Board certifications, to ensure there are no gaps in coverage and to support Bylaws, privilege delineation requirements, TJC and CMS regulations, and according to best-evidenced based practice, policy and procedure.

Under direction of the Manager, liaises between Medical Staff and administration, communicating sensitive and confidential issues including credentialing and peer review. Interacts directly with a variety of internal and external customers. Uses judgement and discretion to maintain peer review protection.

i. Verifications of affiliation with South Shore Hospital to outside sources (Hospitals, Practices, Managed Care) as needed

Under the direction of the Manager, supports and participates in the development of departmental goals, objectives, guidelines, policies, and standard operating procedures.

Provides executive level administrative office support including but not limited to, scheduling meetings, drafting professional correspondence, researching and preparing information for Medical Staff executive leadership, and providing professional assistance to various chairpersons regarding privileging, credentialing, and Medical Staff Bylaws, Rules and Regulations, and policies and procedures.

Maintains ongoing education and compliance with current best-evidenced based Medical Staff Services practices, CMS, TJC, and State regulations and standards and parliamentary procedures.

Performs all functions according to established policies, procedures, regulatory and accreditation requirements, best-evidenced based practice, as well as applicable professional standards. Provides all internal and external customers of SSH with an excellent service experience by consistently demonstrating our core behaviors each day.

6. Develops, maintains and updates Medical Staff Website as needed.

7. Technology – embraces, supports, and is engaged in technological solutions to work processes and practices. Contributes and is actively engaged in the automation of credentialing and privileging processes.

8. Safety Awareness - fosters a "Culture of Safety" through personal ownership and commitment to a safe environment.

10. Assists in the preparation for Credentials Committee and other meetings as needed.

11. General Office Tasks
a. Filing as indicated in distribution of tasks
b. Faxing as necessary to ensure the flow of documentation
c. Copying as needed.
d. Coverage of main medical staff services phone as needed.

12. Participate in the orientation of all new medical staff.

ESSENTIAL FUNCTIONS (Cont.)

I. Technology and Learning
a. Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b. Embraces technological advances that allow us to communicate information effectively and efficiently based on role.

Required additional Knowledge, and Abilities

Individual who is highly organized, detail oriented and able to handle a multitude of tasks.
High level of personal computer skills.
Excellent interpersonal skills.
Excellent verbal/written skills, including accurate and concise minute, and report presentation skills.
Knowledge of JCAHO, federal and state regulations.
Medical terminology knowledge.
CPCS preferred.
Minimum Education - Preferred

Two years college education is preferred. National Certification as a Medical Staff Services Professional is preferred. Associate's degree in business or equivalent preferred.

Minimum Work Experience

Must possess strong knowledge of medical staff office administration as normally obtained through three (3) years experience in healthcare, paralegal, managed care or credentialing. Requires knowledge of medical terminology and professional executive interface. Must possess strong professional verbal and written communication skills. Requires astute judgement in human relations skills to interface and communicate in an articulate manner with Medical Staff, administrators, legal counsel and hospital personnel. Requires proficiency in MS Office and credentialing software and ability to work with common office software and personnel.