Supv Med Staff Affairs- Thomas Hospitals

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's Degree in business or a health related field, OR related experience deemed equivalent.

2. Serves as a Notary Public for the State of West Virginia.

EXPERIENCE:

1. Five (5) years of progressive relative experience.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Manages and coordinates initial credentialing and privilege delineation activities in accordance with the Medical Staff Bylaws, Rules and Regulations, and TJC standards.

2. Manages the process for all new medical staff and allied health applications managing the verification of all applicant background information and obtaining references in accordance with Medical Staff Bylaws complying with TJC standards and federal regulatory requirements as outlined in verification standard.

3. Monitors applicant information; evaluates adequacy and quality of information, and pursues additional information if necessary.

4. Manages the process of biennial reappointment by coordinating the results of quality and appropriateness review and other outcome data with requests for reappointment in accordance with Medical Staff Bylaws complying with TJC standards and regulatory requirements.

5. Notifies medical staff and allied health applicants of governing body actions relative to staff membership and clinical privileges. Disseminates information regarding credentialing and privileging decisions to appropriate hospital personnel.

6. Maintains accurate and current computerized physician database and generates credentialing statistical reports and rosters as necessary. Disseminates physician-specific information to all areas of hospital.

7. Maintains confidential credentials files of all members of the medical staff and allied health staff.

8. Manages process for verifications regarding present and past medical staff members to outside hospitals/managed care organizations/agencies in a timely manner.

9. Accountable for maintaining compliance with the federal regulations as outlined in the Health Care Quality Improvement Act of 1986. Acts as Hospital's authorized representative in matters dealing with the National Practitioner Data Bank.

10. Manages and conducts an orientation program for new medical staff appointees outlining their duties and responsibilities as listed in the Medical Staff Bylaws, Rules and Regulations. Arranges appropriate orientation of new medical staff members, to all pertinent areas of the hospital.

11. Participates in TJC and State Department of Health accreditation survey visits by meeting with surveyors and providing information as required.

12. Maintains familiarity of the Medical Staff Bylaws, Rules and Regulations and interprets for the benefit of medical and hospital staff as needed.

13. Analyzes and interprets TJC medical staff standards and monitors compliance, and recommends revisions in procedures as necessary to assure maintenance of hospital accreditation and licensure.

14. Maintains current knowledge of state laws, federal regulations and accrediting agency standards in order to assure compliance with such.

15. Assures confidentiality of medical staff activities as they relate to peer review, quality assurance and medico-legal issues.

16. Provides statistical data in response to surveys and inquiries regarding medical staff program composition and activities.

17. Prepares and distributes monthly call schedules.

18 Performs payroll functions for the employed medical staff members.

19. Coordinates medical staff, department, and committee, ad hoc and special meetings per bylaws. Prepares agenda and related supporting material for the Medical Executive Committee, working in conjunction with the President of the Medical Staff. Attend meetings and assure documentation of proceedings and provides information to committee members as necessary. Assure follow-up of all actions taken.

20. Prepares and distributes to the governing body a report of medical staff activities as reviewed by the Medical Staff Executive Committee and indicative of pertinent recommendations directed to the governing body.

21. Counsels and orients Medical Staff officers, department and committee chairpersons regarding required duties to maintain consistency in functions.

22. Facilitates inter-organization communication between clinical services and monitoring committees and acts as a liaison between the organized medical staff, administrative, ancillary departments, governing body, patients, physician offices, public, medical associations and societies, accrediting and licensing bodies, managed care entities, other healthcare providers/facilities and outside agencies.

23. Coordinates the review and revision of the Medical Staff Bylaws, Rules and Regulations by incorporating all current TJC medical staff standards, related TJC standards and current state and federal regulations. Assists the Medical Staff and Legal Counsel in the development of appropriately worded amendments.

24. Assists the medical staff leadership in disciplinary matters. Maintains knowledge and participates in Fair Hearing Plan procedures as necessary. Prepares documentary evidence as required and coordinates reporting to external regulatory or licensing authorities as required.

25. Maintains roster of medical staff members and distributes information as necessary. Develops and distributes specialized rosters as specific needs are identified.

26. Assists employed medical staff members with reimbursement expenses.

27. Maintains current Notary Public commission and provides notary services to medical staff, hospital personnel and patients as needed.

28. Prepares annual department non-salary expense budget, FTE budget and capital expense budget. Assures fiscal responsibility of the Medical Staff Department; responsible for the maintenance of all supplies necessary for the efficient operation of the department adhering to applicable budgets.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Cognizant of environmental factors, infection control issues and maintains a safe environment.

SKILLS AND ABILITIES:

1. Ability to be scheduled for work based on operational needs of the hospital.

2. Possesses the ability to deal tactfully and harmoniously with guests.

3. Must have the ability to make sound, independent judgments, and also be able to collaborate with members of the medical staff, medical staff leaders, and other members of the hospital team in an appropriate fashion.

4. Must have the ability to comprehend and perform oral and written instructions and procedures.

5. Must have effective reading and comprehension skills.

6. Must have strong communication skills, written and verbal.

7. Must have ability to perform concentrated and complex mental activity with frequent involvement in complex and highly confidential situations.

8. Must have the ability to work successfully under highly stressful conditions, and must be capable of adapting to varying workloads on a constant basis

9. Must demonstrate excellent interpersonal and communication skills.

10. Requires a knowledge base of medico-legal issues and laws, regulatory agency requirements and standards, medical terminology, computers, word processing, business English and composition.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Address:

WVU Medicine is proud to be an Equal Opportunity employer. We value diversity among our workforce and invite applications from all qualified applicants regardless of race, ethnicity, culture, gender, sexual orientation, sexual identity, gender identity and expression, socioeconomic status, language, national origin, religious affiliation, spiritual practice, age, mental and physical ability/disability or Veteran status.