Director of Medical Staff

This position oversees, and is responsible for the appropriate compliance, all activities for which the Medical Staff Department and the Credentials Verification Organization (CVO) are responsible regarding federal and state requirements, The Joint Commission (TJC), National Committee for Quality Assurance (NCQA), Medical Staff Bylaws, Rules and Regulations, and Credentialing Policies and Procedures. This role coordinates the efforts of the organized Medical Staff, Advanced Practice Professionals (APP) and Renown Health System Employees at both the individual facility and system levels.

This position is responsible for the credentialing and privileging processes, the enrollment processes and all other identified internal processes for the Medical Staff and APP Staff at Renown Regional Medical Center, Renown South Meadows Medical Center, Renown Rehabilitation Hospital and Renown entities (as applicable). This position is responsible for the performance of CVO activities and services for all entities as contracted by Renown or its hospitals.

The director serves as the liaison between the Health System Administration and Medical Staff for purposes of communicating requirements of the System to the Medical Staff (and vice versa) as well as between the System Administration and Medical Staff for matters that involve the system leadership and their active participation. Additionally, the Director will be an internal consultant for all department leaders.

Responsibilities include:

• Directs and provides general guidance to the various functions of the Medical Staff Office to assure continued accreditation by TJC, NCQA, and other regulatory organizations.
• Creates and develops new internal policies and procedures in conjunction with system leadership and legal counsel to demonstrate compliance with new and revised standards from TJC, NCQA, and CMS.
• Interprets, explains and follows regulatory guidelines, including Renown Medical Staff Bylaws, Credentialing & Privileging Manual, Rules and Regulations, and pertinent hospital policies and procedures. Understands current best practices for their area as well as offering alternatives to help align with Renown’s strategic plan
• Serves as internal super user for credentialing software as well as internal resource for department members. Oversight for the creation and distribution of reports from the software for customers.
• In conjunction with hospital and system leaders, create and revise privilege forms. Recommend and monitor advancements for future incorporation.
• Serve as an internal representative of the department in facility and system meetings to ensure optimal coordination, consistent compliance, and, when needed, to advocate for department needs.
• Provides orientation and training to new physician leaders and committee members and the Board of Directors (on an as-needed basis).
• Oversees medical staff committee functions and assists in peer review functions to help ensure findings and outcomes are appropriately reviewed, communicated and documented.
• Directs all of the various programs, and initiatives of the department to maximize efficiency and avoid overlapping/competing priorities.
• Manage the process for updates and revisions to policy as well as department programs to ensure compliance with regulatory and accreditation standards, government legal requirements, Renown policy and best practices.
• Directs the functions of the Medical Staff Office.
• Provides general oversight of all staffing functions, offering support and assistance to downstream leaders for their staff. Create educational material and plans for department members as well as assist members pursuing professional certifications.
• Operationally manages department budget and productivity and evaluates expenditures.
• Performs and analyzes department functions through audits, meetings with staff, etc., as well as develop corrective action for deficiencies
• Facilitate Medical Staff Office training and workshop sessions
• Ensure that standard workflows and processes are routinely evaluated for compliance with current standards, department needs, and industry best practice.
• Helps to foster teamwork and collaboration across the department though collaboration and partnerships.
• Always conducts and maintains themselves in an appropriate and professional manner when in the community and serving as a representative of the hospital. Supports department operations through a demonstrated understanding of department functions. Serves as a backup for Manager(s) in his/her absence or when needed.
• Supports department operations through a demonstrated understanding of all department functions.
• Create and optimize efficient, timely, compliant credentialing and enrollment processes to best support clinical care

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. Bachelor's degree required. Master’s Degree preferred. Ten years of demonstrated experience can be substituted for education.

Experience:

Ten years of experience in healthcare is required with five years in management, two in credentialing, two in enrollment and two in provider relations

License(s):

None

Certification(s):

Two of the following certifications through NAMSS are required at the time of hire, and all three must be obtained within two years of hire: CPCS, CPMSM, or CPES.

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.