<Compensation: job code>: Manager, Medical Staff Office

JOB DESCRIPTION

JOB TITLE: / Manager, Medical Staff Office / GRADE: / 13
DEPARTMENT: / Medical Staff Services / JOB CODE: / NMB22
FLSA: / Exempt / JOB FAMILY: / BM
REPORTS TO: / .
Chief Medical Officer / APPROVED BY: / BL
DATE: / 11/10
Revised: 12/2015

I. GENERAL SUMMARY:

Under the direction of the Chief Medical Officer, the Manager, Medical Staff Office directs day-to-day operations of key administrative and operational functions of the Medical Staff Office. The manager is responsible for supervising the key operational procedures, ensuring all credentialing activities meet current applicable accreditation standards (CMS, Joint Commission, NCQA, BORM, etc.) and providing professional analysis, research, and administrative support to the elected President of the Medical Staff and other physicians leaders as needed.

PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:

·  Assures the education, training, current competence, current licensure, employment history and malpractice history are verified through primary sources and that applicants are approved by the Board of Trustees before practicing.

·  Supervises the processing of renewal applications in compliance with Joint Commission standards for timely processing within the two year timeframe and develops procedures to monitor staff performance in adhering to these standards and timeframes.

·  Assures Medical Staff members maintain current licensure, prescribing privileges and certifications, training and employee health screening; by establishing effective monitoring and compliance mechanisms.

·  Generates reports as needed by Employee Health Services and the DPH to demonstrate compliance with mandatory immunization and TB screening regulatory requirements.

·  Develops and maintain a mechanism to track compliance with mandatory FPPE standards and timeframes.

·  Works collaboratively with the Department of Patient Safety and Quality Improvement to ensure OPPE activities are integrated into the reappointment processes.

·  Develop credentialing and privileging criteria as requested by medical staff leadership, utilizing appropriate reference sources at NAMSS and other organizations.

·  Responsible for completion of hospital credentialing and re-credentialing activities for delegated health plan, in compliance with NCQA audit standards.

·  Assess Hospital and Medical Staff policies and procedures and make appropriate revisions as required by internal process changes, or changes in accreditation standards or applicable laws.

·  Provides management of the Supervisor and Project Specialist staff in the Medical Staff Office by providing coaching, feedback, and suggestions for improved performance.

·  Create and monitor departmental budget variance process and makes recommendation to the budget process by assessing departmental needs for education, equipment, or staff development activities that require financial support.

·  Provide direct administrative support, including creation of agenda, minutes and effective tracking mechanism for follow up for Credentials Committee, Medical Board, Bylaws Committee and Physician Health and Wellness Committees.

·  Maintains continuous surveillance of changes to NCQA, Joint Commission, licensing Board or CMS requirements and ensures medical staff executive documents, including Bylaws, Medical Staff Rules and Regulations, and policies reflect current accreditation and licensure requirements.

·  Work collaboratively with GME Office to ensure attending staff physicians are compliant with ELM requirements for physician education.

III.  JOB REQUIREMENTS:

A.  AGE SPECIFIC COMPETENCIES:

1.  Not Applicable

B.  JOB KNOWLEDGE AND SKILLS:

1.  Experience in developing credentialing criteria for new procedures, changes in practice, or as required by health plans to ensure competency of providers

2.  Ability to independently research situations that are new or without precedent to meet internal needs as they relate to privileging, staffing, or onboarding new providers.

3.  Comprehensive understanding of CMS, Joint Commission, and NCQA, credentialing standards and ability to create documentation systems to ensure internal and external auditors of compliance.

4.  Database skills, including ability to create and design reports utilizing MD staff or Access databases.

5.  Understanding of NPDB reporting requirements.

6.  Excellent interpersonal skills and a thorough understanding of team management concepts with a commitment to practicing this management approach.

C.  EDUCATION:

1.  Bachelor’s degree in Healthcare Administration, Business Administration, or similar required.

D.  EXPERIENCE:

1.  At least five years’ experience in a medical staff services office, preferably within an academic medical center.

2.  At least three years of supervisory experience include interviewing, hiring, coaching, and evaluating staff performance.

An equivalent combination of education and experience, which provides proficiency in the areas of responsibility listed above, may be substituted for the above education and experience requirements.

E.  LICENSES, ETC.:

1.  Certification as “CPMSM” (Certified Professional Medical Staff Management)

IV.  WORKING CONDITIONS/PHYSICAL DEMANDS:

1.  Normal office work environment.

2. 

AMERICANS WITH DISABILITIES STATEMENT:

Must be able to perform all essential functions of this position with reasonable accommodation if disabled.

The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed, as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Tufts Medical Center reserves the right to modify position duties at any time, to reflect process improvements and business necessity.

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