Summary of Position: This position is responsible support the Credentialing Office and all its functions. This position reports directly to the Director of Medical Staff Quality and performs tasks and duties in the area of credentialing and privileging and its related areas.

Primary Job Responsibilities:

Duties: Organizes in conjunction with the Director of Medical Staff Affairs and credentialing team the daily operations of the Credentialing Office.

Reappointments Process: Organizes and maintains the reapplication process. Processes the reapplications, tracks responses, and ensures completeness of the reapplication. Analyzes and compares documentation received against the previous application for any discrepancies. Determines whether discrepancy is a potential “red flag” requiring further investigation. Maintains the integrity of the software. Maintains the credentialing and quality files.

Meeting Preparation and Support: Supports the Credentialing Committee preparations. Prepares, transcribes and conducts follow-up work required for the sections of the Credentials Committee that involve the workflow, OPPE. Takes minutes, transcribes and conducts follow-up work required by the Medical Executive Committee. Supports and assists in the preparation of the Board Summary. Prepares the agenda, takes minutes, transcribes, and performs work required for the Bylaws Committee. Pulls applicable data as requested for meeting prep.

OPPE/ FPPE: works in conjunction to follow Ongoing Evaluation schedule. Collects, tabulates and prepares the reports. Records evaluation recommendations made by the department chair or designee.

Joint Commission Preparation: Responsible in conjunction with the Director of Medical Staff Affairs for all preparations required to maintain readiness and ensure compliance with medical staff standards. Reviews standards annually for compliance. Works collaboratively with the Director of Medical Staff Quality on new medical staff standards as appropriate. Creates corrective/compliance plans of actions as necessary. Performs credentialing file audits periodically.

Bylaws: Audits bylaws, rules, and regulations for changes. Researches and prepares proposed amendments. Supports the approval process for amendments. Updates the medical staff of significant changes in conjunction with the Director of Medical Staff Quality. Ensures that the documents are reviewed periodically.

Medical Staff Policies and Procedures: Reviews, revises and maintains the current medical staff policies and procedures. Creates new policies as needed in conjunction with the Director of Medical Staff Affairs.

Miscellaneous Medical Staff Related Tasks: Assumes responsibility for additional tasks related to the medical staff/ credentialing functions requested by other departments or related agencies/organizations.

Minimum Qualifications: Associates degree required. Minimum of 2 years in a healthcare related field required. Associates degree requirement can be replaced with three years of credentialing experience or CPMSM or CPCS certification.

Certifications / Licensure: CPMSM or CPCS certification required within 4 years of hire date.