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Job: Director, Medical Staff Administration

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Job Description

REPORTING RELATIONSHIPS:   Medical Staff Coordinators, Contract Coordinator, CME Coordinator, GME Manager, Chaplain.
JOB SUMMARY:  Administrative direction for Medical Staff Services, GME, Contract Services, CME and Spiritual Care.  Responsible for department operations, budgeting, planning, development of policies and procedures, and compliance with Medical Staff Bylaws and regulatory guidelines.


1.      Consistently supports and communicates the Mission, Vision and Values of St. Joseph

        Medical Center.
2.      Follows the St. Joseph Medical Center Guidelines related to the Health Insurance Portability and
        Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected
        Health Information (PHI).
3.      Promotes a culture of safety for patients and employees through proper identification, proper
        reporting, documentation and prevention of medical errors in a non-punitive environment.
4.     Supportive of the compliance program set forth by IASIS and demonstrated by:
  1. Upholds the Standards of Conduct and Corporate Compliance.
  2. Adheres to dealing appropriately and fairly with employee misconduct.
  3. Enforces all compliance policies as they pertain to his/her area.
  4. Provides and assures timely compliance education as requested by the Regional Compliance & Safety Officer and/or through corporate initiatives.
5.     Directs Medical Staff Services (MSS) for the Hospital and Medical Staff including development of short and long term strategic plans.
6.     Directs MSS staff to assure adequate FTEs, training/orientation, equipment, and space.
7.     Collaborates with Quality Management to coordinate the quality measures and exchange of information during reappointment and provisional review.
8.     Oversees Medical Staff minutes and quality data/documentation in an effort to limit legal exposures and assure compliance with DNV procedures.
9.     Oversees medical departments and committees to assure that objectives are met and processes are revised as needed to meet the needs of both the Hospital and the Medical Staff.
10.   Responsible for oversight and monitoring of the annual budget and productivity for the MSO.
11.   Works closely with the medical staff to trouble-shoot problems and gather input for improvement.
12.   Controls dissemination of all communication between hospital, medical staff leadership and/or hospital departments to the medical staff members related to department responsibility or quality improvement.
13.   Develops and disseminates the weekly Medical Staff Newsletter to the Medical Staff, Administration, and Directors.
14.   Assists Administration and Medical Staff Leadership in medico-administrative and medico-legal aspects of the medical staff organization. 
15.   Liaison with medical staff and hospital administration and others to assist in maintenance and enhancement of effective relationships.
16.   Schedules and plans Medical Staff events including educational events, Medical Staff Annual meeting, Doctor’s Day, and the Holiday luncheon. 
17.   Serves as a member of the Continuing Medical Education (CME) Committee and serves as a liaison between the Hospital and IASIS CME Coordinator to ensure compliance with TMA Essentials.  Collaborates with Corporate CME Coordinator to provide educational opportunities to the medical staff that aligns with the CME Committee and Hospital Mission.
18.   Initiates and participates in Performance Improvement activities as it relates to the medical staff and quality issues. 
18.   Manages and provides overall support for medical staff leaders.
19.   Provides and assures timely compliance education as requested by the Compliance Officer and/or through corporate initiatives.
20.   Oversees the contract initial approval and renewal process to ensure compliance with established procedures and regulatory guidelines.  Provides direction and guidance to the Contracts Coordinator regarding daily operations, time lines, contract language, processes, and special reports.  Prepares reports and special projects as needed.   
21.   Manages disciplinary processes and ensures timelines and procedures are met as per the Medical Staff Bylaws.  Serves as liaison between legal counsel, Administration, and the Medical Staff in Fair Hearing and disciplinary matters.
22.   Directs the Graduate Medical Education (GME) Department for the Hospital and the Medical Staff including oversight of the GME Manager.  Serves as a liaison between Administration and the GME Committee.
23.   Manages the St. Joseph Medical Center Governing Board meetings, including developing agendas, taking and transcribing minutes, and communication dissemination.  
24.   Directs the Spiritual Care Department and provides oversight to the program.
Medical Staff Services:
1.     Attends the Credentials Committee, Medical Executive Committee, and the Performance Improvement Committee meetings in order to interact with the Medical Staff and gather input about medical staff needs and to act as a Medical Staff Bylaws resource. 
2.     Manages the MEC meeting including developing agendas, taking and transcribing minutes, follow-up, and communication dissemination.
3.     Monitors medical staff action for adherence to medical staff bylaws, applicable law, state and federal regulations, and DNV requirements and communicates noncompliance to the Chief of Staff and the CEO.
4.     Interprets medical staff bylaws, applicable law, state and federal regulations and DNV requirements to the Medical Staff.
5.     Analyzes and recommends changes to the medical staff bylaws on an on-going basis to conform with internal and external changes.
6.     Assures excellent customer service in the Medical Staff Office.
7.     Assures coordination of quality improvements activities between the Quality Management Department and the Medical Staff Department at provisional review and reappointment.
8.     Designs reports and systems to support the credentialing process.  Manages information dissemination to Hospital Operating System ensuring records are uploaded and correct.


MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:  Works closely with the Medical Staff, Hospital Staff, senior management, hospital directors, external agencies, Medical Education, Medical Records, and Quality Management.  Requires excellent oral communication skills, strong interpersonal and management skills, leadership and analytical abilities.  Position further requires independent problem solving, decision making and negotiating abilities.  Must be able to develop trusting relationships with medical staff and department personnel. 
Must demonstrate understanding of the medical staff organization responsibilities and its related bylaws, rules/regulations that govern the organization, DNV standards/survey process/scoring guidelines, other regulatory agency requirements/standards; medico-legal issues and laws relating to medical staff organizations.  Exposure to and responsible for handling confidential information with high degree of sensitivity and diplomacy. Professional attitude and appearance at all times.
WORK EXPERIENCE:  Level of knowledge typically gained through a minimum of 5 years management and/or supervisory experience in the medical staff services field in order to have self-starter skills, effective management and supervisory requirements.
LICENSE/REGISTRATION/CERTIFICATION:  Certified Professional Medical Staff Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS).
EDUCATION & TRAINING:  Bachelor’s degree preferred or equivalent experience with minimum 5 years management and/or supervisory experience in the medical staff services field.  Familiarity regarding functions, services, and compliance requirements and hospital medical staff functions.
For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.


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