Job Abstract

Job Summary

Provides leadership, management, and operational oversight of the Medical Staff Office (MSO), in accordance with the Medical Staffs Bylaws, Rules and Regulations and applicable policies and procedures, as well as Joint Commission standards and CMS Conditions of Participation. The Manager works collaboratively with Hospital Administration, the Medical Staff President, the Credentials Committee, the Medical Executive Committee (MEC), and additional Medical Staff Leaders (appointed, elected, volunteer, etc., such as department chairs, section chiefs, committee members, etc.) to plan, organize, direct, and coordinate the programs and activities of the MSO. The Position reports to the Chief Medical Office for the facility.

Essential Functions

• Coordinates and maintains the MSO "Governance documents" such as the Medical Staff Bylaws, Rules and Regulations, related documents (privilege forms, credentialing manual, etc.) and policies and procedures of the office. Reviews and reassesses governance documents on the regular basis and recommends changes to the MEC and Governing body, as necessary
• Coordinates implantation of all approved programs, projects, and major activities of the MSO
• Provides resources to the Medical Staff Leaders to assist them in carrying out their responsibilities
• Coordinates departmental and committee meetings to include preparing the agenda and taking minutes at the meetings (Credentials, Medical Executive Committee, and General Staff Meeting(s))
• Collaborates with other hospital departments on projects and goals, as necessary
• Oversees the Medical Staff finances
• Oversees the credentialing and privileging process and ensures it meets regulatory standards and the needs of the organization
• Demonstrates working knowledge of standards and regulations from accrediting bodies
• Manages the FPPE and OPPE process for the Medical Staff
• Maintains the credentialing database system (ECHO Credentialing)
• Participates in surveyor activity, including, but not limited to, NJ Department of Health, The Joint Commission, and CMS

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Minimum Education/Certifications
Bachelor's degree preferred or equivalent education/experience.

Minimum Work Experience
Minimum of five years of management experience in one of the following venues: hospitals, managed care, credentialing verification organizations, or ambulatory care. Three years in medical staff services is required. Experience in working with governance processes is essential.

Certification from the National Association of Medical Staff Services (NAMSS) as a Certified Professional Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM) (Preferred)

Must have strong computer, communication, customer service, and writing skills with basic knowledge of medical terminology.