Director Medical Staff Services

Job Description

Overview

The Medical Staff Services Director provides support to the Medical Staff and Advanced Practice Professionals (APP) credentialing process under supervision of the AVP of Medical Staff Services. Responsibilities include management of the credentials verification program, data entry, tracking/trending and maintenance of information essential to the organized Medical Staff, APP and Health Care Industry Representatives.

Responsibilities

• Oversee credentialing activities, report all research and forward to department chairs, medical staff committees, and to the Board for review and action.
• Complete quality control evaluations and the decision-making process for credentialing/privileging.
• Ensure that appropriate documentation is maintained for JCAHO and other accreditation and licensing surveys.
• Ensure coverage of medical staff meetings and provide guidance, resources and support to medical staff officers, committee and department chairs.
• Oversee the preparation of accurate documentation of medical staff organization activities following legal guidelines, JCAHO, and other federal and state requirements.
• Ensure that a monthly summary of all medical staff committee and department activities, actions and recommendations is prepared for review and action by the Medical Executive Committee and to the Board for review and action.
• Ensure that data is entered in the medical staff computer system when new medical staff members are approved by the Board or when changes are made related to privileges or staff status.
• Ensure that computerized information is maintained in a confidential manner.
• Support yearly orientation programs for medical staff officers and department chairs regarding required duties to help them consistently perform their functions.
• Develop and coordinate new medical staff members' orientation program.
• Monitor and remain current on issues related to medical staff bylaws, credentials activities and medical staff policies and procedures manuals.
• Stay current on issues related to JCAHO standards and other accreditation and licensing standards addressing medical staff issues and requirements.
• Remain current and knowledgeable regarding legal requirements related to medical staff activities and contacts legal counsel when necessary.
• Ensure adequate training and high-performance standards are maintained by both on-the-job training and through continuing education programs.
• Evaluate work performance on a regular basis by reviewing productivity and efficiency and adherence to policies and procedures.
• Develop and update departmental policies and procedures manual and job descriptions.
• Prepare the operating, capital equipment, and personnel budgets for the department.
• Prepare annual goals and objectives for the department.

Seniority level

Director

Employment type

Full-time

Notes

Qualifications are not specified in the description. This section preserves the role context and related expectations.