Dir Medical Staff Service

Position Summary:


The Director of Medical Staff Services is responsible for establishing and maintaining continuity in the planning/development/implementation of standards applicable to Medical Staff relating to credentialing, peer review, quality assessment/improvement and administrative functions. Will direct the daily activities of the Medical Staff Coordinator and be responsible for facility-wide preparation, organization and follow-up involved in maintaining hospital accreditation and licensed with the DNV Healthcare Inc as it relates to Medical Staff Services.

Essential Functions :

1. Acts as resources to the medical staff by keeping current with all accreditation standards and regulatory requirements, including State and Federal regulations. Updates departmental policies and procedures as necessary to comply with changes.


2. Assists in developing long-range plans for the medical staff to ensure overall continuity of hospital programs. Establishes good communication with the medical staff, nursing and other hospital departments, and acts as liaison between medical staff and administration.

3. As CME (Continuing Medication Education) Coordinator, works with the CME Committee in developing CME programs, symposia and dissemination of educational materials related to peer review and monitoring and evaluation of activities. Responsible for recording both internal and external CME activities.

4. Supervises the Medical Staff Library under the direction of the Medical Library Committee; maintains books and periodicals.


5. Initiates and processes proposed amendments to the medical staff bylaws, rules and regulations and monitors their enforcement. Maintains a current master copy of the medical staff bylaws, rules and regulations, including the rules and regulations of the respective medical staff departments, and is cognizant of the contents thereof.

6. Guides the medical staff, in concert with legal counsel, through disciplinary processes involving members of the medical staff through coordination with medical staff counsel and the CEO.

7. Responsible for the DNV and ISO certification compliance as the Medical Staff Office Chapter Leader.

8. Oversight of the medical staff performance improvement plan, including the continued enhancement of Physician Quality Profiles, through collaboration with the medical staff and other department of the hospital (Quality Management).


9. Assures continued integration of Peer Review with organization's Quality Management leadership.

10. Responsible for official communications to and from medical staff membership, including newsletters, changes in medical staff membership, changes in privileges to all affected departments, and on-call schedules and updates.

11. Responsible for onboarding, including orientation of physicians, advanced practitioners, medical school students, and residents.

12. Responsible for medical staff budget development and oversight.

13. Prepares the MEC (Medical Executive Committee) monthly summary report of the medical staff activities including the committee indicators and projects for the MEC.


OTHER RESPONSIBILITIES:

1. Other duties as assigned from time to time.

SUPERVISORY RESPONSIBILITIES:

1. The position will have two support staff that report to the Director.

2. Closely integrated with the operations of the Quality Management Department.

EDUCATION, KNOWLEDGE, SKILLS, ABILITIES AND EXPERIENCE:


1. Significant experience in the healthcare industry, with specific ethics/compliance program experience or legal experience.

2. Familiarity with Medicare and Medi-Cal programs.

3. Maintains a high degree of credibility, independence, integrity, confidentiality and trust.

4. Demonstrates sound business judgment and is supportive of the hospital mission and objectives.

5. Strives to develop partnerships, teamwork and good working relationships. Maintains an open management style.

6. Understands the legal regulatory framework of PMHD.

7. Maintains strong writing skills required to write and edict policies and procedures, issues memorandums and compiles program reports.

8. Exhibits good presentation skills with large and small audiences.

9. Must demonstrate ability to exercise professional judgment regarding acquisition, recording, and communication of highly sensitive and confidential information and data.

10. Must have the ability to interact with both internal and external customers. Must maintain calm demeanor during stressful conditions.

11. Must possess organizational skills.

12. Must have computer skills, including working knowledge of word processing, spreadsheet and graphics. The position is expected to work with current software systems, including 1) MIDAS Seeker and 2) Compliance 360 - electronic policy management systems. And 3) hospital-wide email - currently Outlook.

13. Minimum of 5 years acute care hospital experience. Experience in Clinical Services, Quality Management, Compliance, HIPAA, Medical Staff, and/or contracting strongly preferred.