Manager, Medical Staff Office

Employment Type:

Full time

Shift:

Day Shift

Description:

The Manager of Medical Staff Office coordinates and supervises all services in the Medical Staff Office at Gottlieb Memorial Hospital (GMH). They serve as a liaison between the Loyola University Medical Center credentialing office, the Trinity Central Verification Office (CVO), and Gottlieb Medical Staff Office. They serve as a communication liaison internally within Gottlieb, between Hospital Administration, the President of the Medical Staff and the general medical staff.

Position responsibilities:

Medical Staff Office Management:

• Responsible for all aspects of operations within the medical staff office of MNH.

• Supervisory responsibility and oversight of the activities of the Performance Improvement Review Coordinator, Credentials Verification Specialist, Administrative Assistant II, Continuing Medical Education Coordinator, and Hospital Librarian.

• Attend monthly Leadership Meetings to communicate hospital initiatives.

• Manage employee attendance in attendance management software and approve paid time off requests.

• Responsible for supervision, hiring, termination, flex time, annual reviews, and disciplinary action involving the individuals in these roles.

Administrative review of credentials:

• Oversee the process of initial appointments, both permanent and temporary, and privilege expansions through the electronic administrative review system in the credentialing software program (MSOW).

• Involves review of the file, flagging, any issues identified, and preparation of routing slip sent to all required parties including the Department Chair, Chief Nursing Officer, Chief Medical Officer, Credentials Committee Chair, and Medical Staff President.

• Also oversees all of these same steps of reappointment processing.

Medical Staff Office Credentialing:

• Supervises and conducts the Medical Staff Office processes involved in the credentialing of the medical staff including determining eligibility of candidates, collecting initial application fees, initiating launch of application by the CVO as well as processing the immunization requirements and performing the background checks for all initial reappointment files.

Meetings:

• Coordinates and oversees all aspects of regularly held medical staff meetings of the Credentials Committee, Medical Executive Committee, General Medical Staff, Department Meetings, Bylaws Committee, and Well-Being Committee including agenda and preparation of minutes and follow up on medical staff voting issues.

• Ensures compliance with adherence to the Bylaws and accreditation standards for these committees as well as all other medical staff committees.

Appointment Approvals:

• Coordinates the approval process for initial appointments and reappointments of medical staff and allied health medical staff with the Credentials Committee, Medical Executive Committee, and Board of Trustees. Development of agendas, minutes, Board reports and all aspects of Credentials and Medical Executive Committee Meetings involving credentialing and medical staff issues.

• Communicates monthly approvals and resignations to managers, CVO, Information Technology, hospital staff, and medical staff. Notifies the practitioner of initial appointment and provides backup coverage for notification of reappointment approval. Updates marketing webpage for all practitioners.

Corporate Database Credentialing files:

• Enters and maintains confidential information on all appointments and resignations for the medical staff and allied health professionals in the credentialing software system. Generates monthly reports.

Clinical Privileges:

• Release/post the clinical privileges for all initial appointments and reappointments, and suspend privileges as necessary.

• Ensures regular review of clinical privilege forms and performs upgrades within the Privileging Module of the credentialing software system. Assists Chairs and Section Chiefs in the development of privilege criteria numbers.

Access:

• ·For all practitioners, obtain WorkDay number and request Epic access as well as request/enroll provider for electronic prescribing of controlled substances. At GMH and MNH serves as manager for all credentialed medical staff.

• At both hospitals processes all non-colleague view only access requests from physician private practice or billing staff.

• Process access termination requests as well.

• Troubleshoot all access issues with IT for all medical staff.

Budget:

• Responsible for development of the annual budget for the medical staff office, and CME and Library.

• ·Responsible for the Medical Staff Custodial Accounts in the Insight system and attends Monthly Operations Review Meetings as needed to address any variance within these accounts.

• Provide reports to the Medical Staff Treasurer to present to the Medical Executive Committee with regards to the independent custodial account medical staff funds.

Accounts payable:

• Oversee the process of the monthly payments for contracted services, on call medical staff and invoices.

• Serves as coverage backup to perform these activities in Lawson.

Accreditation:

• Update medical staff policies and procedures to ensure maintenance of accreditation standards including involvement/input of Medical Staff Bylaws and Rules and Regulations.

• Serve as owner of all Medical Staff Policies in Policy Manager System.

• Annual update and follow up on Medical Staff Standards in Verge Solutions System.

• Responsible party for Medical Staff Standards for Joint Commission accreditation.

Physician Peer Review Activities:

• Coordinate and oversee physician reappointment processes that interface with ongoing professional practice review (OPPE) and focused professional practice evaluation (FPPE).

• With the assistance of the Physician performance Improvement Coordinator, oversee the performance of OPPE, FPPE, physician peer review, and the management of physician behavioral complaints.

Expiring and Other Physician Reports:

• Oversee the management of medical staff expiring certifications and licenses such as BLS and ACLS, state licensure, DEA, malpractice certificates, etc.

• Also provide management oversight for the processing of National Practitioner Data Bank reports, license censures and revocations, and other issues identified by the continuous query process.

Compliance:

• ·Maintain Stark exemption logs and promote processes and behavior compliant with the Stark and other physician fraud and abuse laws.

Medical Staff Health Standards:

• Oversee the tracking of medical staff influenza vaccination and compliance with other medical staff health standards.

Special projects:

• Assist in special projects for the medical Staff office, including but not limited to the annual dinner dance, CME events, fundraisers, and auxiliary ventures. Assist the Chief Medical Officer with projects such as the Physician Survey and action plan, Emergency Preparedness, software implementation, and various quality improvement and peer review initiatives.

• Participate in leadership programs such as Leadership Development Institutes, Patient Experience messaging and participate in daily Patient Safety Huddles when medical staff information needs to be presented. Draft monthly CMO newsletter.

Reports:

• Run reports and complete surveys from the credentialing system for multiple internal and external sources.

Requirements:

• HS Diploma with 10 years experience, or a Bachelor's Degree.

• Certified Provider Credentialing Specialist (CPCS) must be obtained within a year of hire

At Gottlieb Memorial Hospital, we know you're more than your job. We see you and all of your potential. That's why we invest in our people. Clinical advancement programs, flexible scheduling, tuition reimbursement and day one benefits… at Gottlieb, what's important to you, is important to us. Join our family.

• Benefits from Day One

• Daily Pay

• Career Development

• Tuition Reimbursement

• On Site Fitness Center (Gottlieb Memorial Hospital & LUMC)

• Educational Stipend

• Certification reimbursement (up to 1 certification)

• Referral Rewards

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.