Manager of Medical Staff Services

Manager of Medical Staff Services

The Manager of Medical Staff Services (MSS) assists the Market Director Medical Staff Services with implementation of and compliance with credentialing initiatives/processes. The incumbent is expected to maintain a working knowledge of applicable HCA Healthcare and Parallon Credentialing Processing Center (CPC) policies, accreditation standards and regulations associated with medical staff services, and play a key role in the integration of HCA Clinical Strategies and HCA systems.

At the direction of the Market Director Medical Staff Services, the Manager of Medical Staff Services will:

Supervisor: Market Director Medical Staff Services

Supervises: NA

Responsibilities & Job Functions

1. Medical Staff Administration
1. Develop facility credentialing policies in accordance with accreditation/regulatory standards, HCA Healthcare policies, and medical staff bylaws.
1. Facilitate meetings (develop agendas, maintain meeting minutes, coordinate follow-up) for the following committees:
1. Medical Executive Committee
2. Credentials Committee
3. Peer Review
4. And other committees mandated by governing documents
2. Coordinate the work in matters related to practitioner health and professional conduct, and support functions for continued monitoring.
3. Maintain the official emergency call schedule and records for call compensation payments.
4. Manage correspondence between facility and individual medical staff members, not related to credentialing matters.
5. Provide support functions to medical staff officers in performance of their duties.
6. Collaborate with the Market Director in the development, maintenance, and distribution of medical staff governance documents (i.e. bylaws, rules & regulations, policies) and implementation of an annual review process.
7. Ensure tokens of appreciation and gifts provided to members of the medical staff are reported to the ECO to log on the Business Courtesy Log, in accordance with Ethics & Compliance Policies LL.022, EC.005, EC.006, and EC.008.
8. Coordinate the collection and handling of medical staff dues and other fees in accordance with Ethics & Compliance Policy TRE.001.
9. Participate in planning for future medical staff recruitment.
2. Medical Staff Education
1. Facilitate orientation for new medical staff members (and in partnership with other key stakeholders to include Director of Clinical Informatics (DCI) and IT&S personnel.
2. Collaborate with the Market Director to facilitate orientation for new officers, committee members and governing body.
3. Provide education to administrators and department directors regarding CPC operations and MSSD operations, privileging (including temporary and disaster privileging), and non-privileged practitioner credentialing.
4. Create and acquire students in the Physician Learning Center, making course assignments as appropriate to achieve facility regulatory compliance and safety outcomes.
3. Accreditation and Regulatory Compliance
1. Serve as the facility's subject matter expert regarding relevant accreditation and regulatory requirements related to the medical staff.
2. Notify the CPC, Division and corporate teams of any upcoming or ongoing surveys relative to credentialing, privileging and PPE/peer review activities and functions.
3. Coordinate accreditation, regulatory, and any internal surveys relative to credentialing, privileging and PPE/peer review activities and functions.
4. Respond to any reviews of accreditation and regulatory compliance citations or deficiencies by developing and implementing corrective action plans.
5. Participate in the facility Regulatory Readiness Committee, managing compliance to the medical staff chapter in The Joint Commission Accreditation Manual.
4. Facility-based Credentialing Tasks
1. Apply the credentials evaluation process uniformly to all RFC/applications and R-RFC/re-applications to ensure compliance with internal credentialing procedures.
2. Verify applicant identity in accordance with MSS-004.
3. Forward any updated information received from a practitioner to the division in a timely manner.
4. Analyze any available internal data and information for an assessment of qualifications and competencies for each R-RFC/re-application.
5. Facilitate review, assessment, and authenticated documentation of an evaluation of each application and request for clinical privileges by the section chief / department chairman as required.
6. Facilitate review, assessment and recommendations for each application and request for clinical privileges by the Credentials Committee (if applicable to the facility) and the Medical Executive Committee.
7. Utilize "paper-lite" procedures to facilitate medical staff reviews by maximizing use of iObserver functionality in Cactus.
8. Summarize and prepare credentialing information, including information about flagged concerns, for the board's review and decisions.
9. Collaborate with Division Medical Staff Centralized Services, to effectively manage practitioner access to protected health systems to ensure updates for expired credentials in accordance with CPC-36 and MSS-003.
10. Manage and archive files according to HCA Healthcare and facility procedures and accreditation/regulatory standards.
11. Process practitioner waiver request through the Division Chief Medical Officer (DCMO) prior to presenting to facility-based committees, i.e. Credentials, Medical Executive Committee and Board of Trustees (BOT).
5. Privileging
1. Collaborate and coordinate with Market Director, on the review of eligibility criteria for each clinical privilege or grouping of clinical privileges that require the same qualifications and competencies.
2. Facilitate the review of requests for clinical privileges using the approved eligibility criteria.
3. Participate in assessing the applicability and appropriateness of clinical privileges for each specialty through periodic review with the Marker Director.
4. Facilitate any required regulatory agency reporting of adverse actions taken against a practitioner's medical staff membership or clinical privileges, as directed by facility leaders.
5. Ensure that request for changes to privilege sets are processed through the Centralized Medical Staff Services.
6. Performance Improvement/Peer Review/Patient Safety
1. Coordinate with the facility's quality department to facilitate focused professional practice evaluation (FPPE), and any related evaluation at the conclusion of FPPE or a period of provisional status.
2. Coordinate with the facility's quality department to facilitate ongoing professional practice evaluation (OPPE).
3. Coordinate with facility leadership and Division Medical Staff Services Department in the conduct of internal and external peer reviews.
4. Complete a summary of FPPE, OPPE, and peer review results for evaluation by medical staff leaders as part of the R-RFC process as noted in 4e above, and ongoing as required by policy.
5. In collaboration with the CPC, identify critical MSSD performance benchmarks, measure performance, and take-action to improve when performance is not as desired or expected.
6. Coordinate with the facility's Patient Safety Officer in the medical staff review of occurrence reports, patient complaints, close call data, and SPAE reports.
7. Coordinate with the facility's Patient Safety Officer regarding medical staff participation in any activities performed as part of the HCA Healthcare Patient Safety Organization (PSO), including the appropriate handling of Patient Safety Work Product (PSWP).
7. Risk Management
1. Ensure timely and proper notification of the risk manager regarding possible malpractice or other liability concerns.
2. Coordinate all medical staff disciplinary actions (e.g., formal investigations, professional review actions).
3. Collaborate with the facility's Market Director of MSS to facilitate due process in accordance with the hospitals fair hearing and appeals policy as well as legal and regulatory requirements.
4. In accordance with Ethics & Compliance Policy EC.023, and in coordination with the facility's ECO, submit a Reportable Issue report for any instances of a practitioner providing patient care within the facility without a legally required credential (e.g., license, DEA), or while under a Federal or state sanction, or without having current, approved clinical privileges.
8. National Practitioner Data Bank (NPDB)
1. Manage and maintain the NPDB account as the Data Bank Administrator.
2. Coordinate the completion of the NPDB's Attestation by the facility's Attesting Official at the time of renewal of the facility's registration with NPDB.
3. Subscribe to the "NPDB Insights" e-newsletter; review and communicate any changes in requirements to the appropriate facility executives.
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