Director Medical Staff Affairs & Payer Credentialing

SUMMARY:

Directs the activities of the Medical Staff and payer credentialing.  Works closely with the medical staff to support their organized activities, such as credentialing, department/committee meetings, and quality review activities. Works closely with TMCOne Revenue Cycle to ensure timely payer credentialing and resolving any credentialing-related issues that arise.

ESSENTIAL FUNCTIONS:

Direct the processing of applications for appointment and clinical privileges in an accurate, thorough and timely manner in accordance with the hospital's credentialing policies for medical staff.

Directs the payer credentialing operations, including but not limited to CAQH management and payer credentialing applications.

Directs coordination of data between internal and external systems, including licensures, CAQH and NPPES.

Develops innovative strategies for improvement to ensure optimal functioning of the department and compliance with all state, federal and regulatory requirements, policies and processes.

Ensures that the Medical Staff Bylaws are current with state, federal and regulatory requirements and that all processes of credentialing, privileging and medical staff appointment of physicians and relevant licensed independent practitioners are in compliance with the bylaws.

Reviews, interprets and provides consultation and timely advice to administration regarding regulatory guidelines, including medical staff bylaws, corrective actions and the fair hearing process, rules, regulations and policies.

Reviews, oversees and advises medical staff leadership and hospital administration regarding credentialing/privileging of appointments, reappointments, and privilege expansion/reduction requests; assesses whether individuals with clinical privileges provide services within the sco·pe of privileges.

Develops and directs systems and processes for professional practice evaluation of new and existing medical staff members.

Advises and supports the relevant Medical Staff Committees on matters of medical staff credentialing, professional practice evaluation and implementation performance improvement plans.

Develops and monitors the operating budget for the department.

Directs the development, enhancement and maintenance of the credentialing database; assures accuracy of data entry; monitors critical data for analysis and coordinates functional report generation.

Creates a culture of excellence and customer service in all processes with all internal and external customers including current and future members of the medical staff and other providers, clinical and administrative leaders and all external representation.

Has oversight over the reappointment process ensuring applications are sent to those eligible for reappointment.

Ensures information in the medical staff database is correct and up to date. Maintains the automated clinical privilege system. Physician data and clinical privileges are updated in the data file in a timely manner following completion of the reappointment cycle or when periodic changes occur.

Researches information on new privileges, new types of practitioners and their scope of practice, and scope of practice of existing practitioners.

Maintains confidential files on all medical staff members. Credentials files reflect current licensure, insurance, board certification status and current clinical privileges.

Oversees the following processes and assures compliance with the Medical Staff Bylaws and associated policies: Professional Practice Evaluation, Professionalism Evaluations, Practitioner Health processes.

Oversees and assures accurate payment for medical staff leader’s time spent on relevant duties.

Stays abreast of Joint Commission standards as well as other regulatory requirements.

Asses and ensures compliance with payer credentialing standards.

Assesses medical staff compliance with regulatory standards.

Communicates identified deficiencies with the appropriate medical staff leaders, hospital administration and hospital staff. Supports corrective action on identified deficiencies as appropriate.

Acts as day to day liaison between members of the medical staff and hospital administration.

When appropriate, acts as a representative of the medical staff and effectively and professionally communicates on their behalf.

Supports the medical staff in operating in accordance with their bylaws and related policies.  Informs appropriate medical staff leadership and hospital administration when bylaws and related policies need to be amended to comply with regulatory requirements or to ensure the orderly operation of the medical staff.

Responsible for interviewing, hiring, and on boarding staff following HR guidelines; oversees orientation, training, and mentoring, communicates and evaluates employees’ performance.

Coordinates, organizes, and attends medical staff meetings. 

Adheres to and supports team members in exhibiting TMCH values of integrity, community, compassion, and dedication. 

Adheres to TMCH organizational and department-specific safety and confidentiality policies and standards.

Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION:  Bachelor’s degree in a medical, business, or related field, or an equivalent combination of relevant education and experience.  Master’s Degree Preferred.

EXPERIENCE:  At least five (5) years of experience as a medical staff manager or director or a similar position in the medical field preferred and at least one (1) year experience in payer credentialing

LICENSURE OR CERTIFICATION: Must be CPCS or CPMSM certified.

KNOWLEDGE, SKILLS AND ABILITIES: 

·         Knowledge of the medical staff bylaws and related policies.

·         Knowledge of credentialing process for medical staff

·         Skill in providing customer service.

·         Ability to prioritize and manage timelines.

·         Ability to complete routine reports and correspondence.

·         Ability to listen and accurately interpret others’ communication or instructions to take appropriate action.

·         Ability to speak effectively before groups of customers or employees of organization.

·         Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.

·         Ability to deal with problems involving a few concrete variables in standardized situations