Medical Staff Services Coordinator

Medical Staff Coordinator

The Medical Staff Coordinator serves as a resource to, and collaborates with, Chief of Staff (COS)/Medical Director, Medical Staff, Advanced Practice Professionals (APP) and hospital administration. Responsible for maintaining and monitoring the operational processes, and Medical Staff governance functions of the office of Medical Staff. In collaboration with the Credentialing Verification Office (CVO) the Medical Staff Coordinator will act as a liaison between the CVO and the medical staff office, supporting the credentialing and privileging application process. The Medical Staff Coordinator will maintaining strict confidentiality and ensuring compliance with organizational policies and accrediting and regulatory agencies.

Key Responsibilities

• Coordinates requests for credentialing and privileges to CVO, including but not limited to: appointments, re-appointments, status changes. LOA and other updates.
• Coordinates the credential file from the CVO through the MEC and BOG approval process per Medical Staff Bylaws, including attending meetings of Medical Committee of Board of Governors
• Coordinates and collaborates with residency program directors, medical schools and others, to facilitate Fellow/Resident/Student/Observer rotations.
• Processes residents and clinical fellows and performs review and analysis, identification and follow up of any missing items; prepares files for review and recommendation by the Medical Staff.
• Responsible for the input of the fellow and resident information into the credentialing database MD-Staff, unless otherwise assigned
• Coordinates the fellow/resident/student/observer paperwork with the affiliated facilities to ensure completion of all required documents in advance of rotation start date.
• Coordinates performance review of Residents per the Medical Staff Bylaws
• Coordinates the annual resident and fellow report for Corporate Medical Affairs
• Responsible for the collection of the appropriate facility-specific forms required for onboarding
• Supplies affiliate hospitals with information needed for SHC providers to be credentialed and privileged at the affiliate.
• Responsible for the facilitation and execution of the on and off boarding and orientation of all providers. (Including but not limited to: coordinating PDCF process, collection of required documents, coordination of computer training, local drug testing, criminal background checks, orientation) and provide necessary information to the CVO.
• Collaborates with pharmacy director to enroll all providers in EPCS (electronic prescription of controlled substances).
• Responsible for working with the Medical Staff on the development and delineation of clinical privilege and approval/maintenance of the privilege forms every 5 years, per the Medical Staff Bylaws.
• Responsible for the License Procurement Renewals (in coordination with the Telehealth License Coordinator), telehealth license request forms, CME requirements/tracking and monitoring of expirations.
• Performs ad hoc job-related duties as assigned.

Communication and Coordination:

• Maintains open communication and collaboration with the CVO on any pertinent information related to the Medical Staff and advanced practice professionals.
• Responsible for the development, planning, and operational management of the Medical Staff committee structures; promotes and enhances good communication and a positive working relationship.
• Provides administrative support to Medical Staff and Advanced Practice Professionals, as required.
• Manages maintenance of curriculum vitae and academic postings and publications and submits to the Chief Medical Officer (CMO), unless otherwise assigned.
• Ensures coordination and data collection for HDQ Provider Enrollment to ensure timely enrollments, unless otherwise assigned.
• Manages and maintains Medical Staff travel requirements and an annual summary reports submitted to the CMO, per the Medical Staff Bylaws; unless otherwise assigned.
• Generates queries and reports from credentialing and privileging database as requested.
• Works with COS on call schedules, timekeeping, contracts, budgets, expenses, and communicates to on and off site providers

Quality:

• Collaborates with COS, Performance Improvement Director, and other leaders to develop OPPE indicators, data sources, and data submission responsibilities and process.
• Coordinates, tracks and monitors the Medical Staff and Advanced Practice Professional Staff for OPPE (Ongoing Professional Practice Evaluation) and FPPE (Focused Professional Practice Evaluation) process ensuring compliance with regulatory standards and Medical Staff policies.
• Coordinates review of OPPE data by the Chief of Staff and/or President of the Medical Staff every six months in order to comply with SHC standards. Supplies this information to CVO for processing reappointments.
• Collects data on low or no volume providers from outside sources to meet regulatory requirements.
• Ensure required certification, training to support privileges/prerogatives and annual education is completed and maintained. (i.e SHINE modules, PALS, BLS, etc)

Compliance:

• Maintains legacy paper credential files (according to retention schedule). Creates and maintains provider log for all paper files.
• Interprets federal, state, local, and government/insurance agency regulations and guidelines, as well as local Medical Staff Bylaws, SHC Hospital Regulations and Procedural Rules, policies and procedures; and advises providers, management, and administrators on compliance issues as appropriate. Participants in the ongoing assessment of governing documents to ensure continuous compliance, and addresses identified gaps with providers and COS as needed.
• Facilitates due process that complies with the Medical Staff Bylaws, as well as applicable legal, state, and regulatory requirements.
• Participates in the Joint Commission Surveys regarding privileging, Medical Staff functions, quality, policies and procedures, Medical Staff Bylaws and Hospital Regulations and Procedural Rules.
• Ensures Medical Staff Bylaws are reviewed and updated, as needed, as well as timely compliance with HDQ-Amendment Team recommendations.
• Creates, reviews and updates medical staff policies, and facilitates approval process and upload into Compliance 360 software, unless otherwise assigned.
• Facilitates obtaining maintenance of certifications and board certification waivers according to the Hospital Regulations and Medical Staff Bylaws.
• Assist the Chief of Staff and/or the President of the Medical Staff in the annual election of Medical Staff officers; unless otherwise assigned.

Medical Staff Bylaws and Policies & Procedures:

• Ensures Medical Staff Bylaws are reviewed and updated, as needed, as well as timely compliance with HDQ-Amendment Team recommendations.
• Creates, reviews and updates medical staff policies, and facilitates approval process and upload into Compliance 360 software, unless otherwise assigned.
• Facilitates obtaining maintenance of certifications and board certification waivers according to the Hospital Regulations and Medical Staff Bylaws.
• Assist the Chief of Staff and/or the President of the Medical Staff in the annual election of Medical Staff officers; unless otherwise assigned

Meetings:

• Schedules, coordinates, prepares agenda, and takes minutes, for Medical Staff committees as outlined in the Medical Staff Bylaws.
• Prepares BOG summary reports of credentialing/privileging recommendations and ensures flow of information and action items for Medical Staff committees outlined in the Medical Staff Bylaws and communicates credentialing decisions to the CVO.

Required Qualifications:

• High school diploma or equivalent (GED) required
• Ability to communicate effectively, both orally and in writing with all levels of the organization required.
• Ability to use independent judgment and to manage and impart confidential information required.
• Excellent interpersonal skills required.
• Excellent verbal/written skills, including accurate and concise minute and report presentation skills required.

Preferred Qualifications:

• Associate Degree in Medical Staff Services preferred, or combination of education and management experience deemed equivalent
• Three years in Medical Staff Services and/or five years in hospital experience, preferred.
• Knowledge of Medical Staff affairs operational processes preferred.
• Knowledge of related accreditation and certification requirements preferred.
• Knowledge of federal and state regulations preferred.
• Working knowledge of clinical and/or hospital operations and procedures preferred.
• Working knowledge of Medical Staff policies, regulations, and bylaws and the legal environment within which they operate preferred.
• Individual who is highly organized, detail oriented and able to handle a multitude of tasks preferred.
• Experience with one or more Joint Commission surveys, including the preparation of Medical Staff for interview and attendance/participation in previous survey is a requirement a plus.
• Certified Provider Credentialing Specialist (CPCS