Director, Medical Staff Office (KFH/HP)

Job Summary:

Oversees and removes barriers to resolve issues during the reviews and requests for primary source information and verifications to focus on long-term needs. Enables relationships for collaboration with external entities. Proactively identifies, suggests improvements to, and provides resolution for complex gaps in vendor relationships. Determines expectations for collaborations to disseminate practitioner information during application process. Evaluates applications and supporting highly complex documents. Oversees and provides consultative efforts on complex cases regarding implementation of guidelines and requirements. Leads definition of credentialing and privileging process for all practitioners/providers. Oversees alignment of organization-wide priorities to evaluate adverse data. Drives adherence to establish priorities when facilitating efficient cost-effective due process. Provides guidance to evaluate data inconsistency. Oversees and removes barriers for training and regulatory awareness. Identifies training outcome priorities, develops plans for, and assists in strategic development of training and orientation of physician leaders. Aligns standards and directs review of enrollment applications. Collaborates with internal groups to progress and troubleshoot enrollment status. Forecasts future needs for the maintenance of data systems, applications, and controls. Assists in the development of new strategies for credentialing data analyses. Develops and maintains guidelines in collaboration with internal leaders for database structures and data use. Regularly collaborates with external/internal leaders, participates in the development strategies for adherence during development of corrective action plans. Sets expectations for and leads collaborations with others to conduct high-impact audits and site visits.

Essential Responsibilities:

• Prepares individuals for growth opportunities and advancement; builds internal collaborative networks for self and others. Solicits and acts on performance feedback; drives collaboration to set goals and provide open feedback and coaching to foster performance improvement. Demonstrates continuous learning; oversees the recruitment, selection, and development of talent; ensures performance management guidelines and expectations to achieve business needs. Stays up to date with organizational best practices, processes, benchmarks, and industry trends; shares best practices within and across teams. Motivates and empowers teams; maintains a highly skilled and engaged workforce by aligning resource plans with business objectives. Provides guidance when difficult decisions need to be made; creates opportunities for expanded scope of decision making and impact.
• Oversees the operation of multiple units within a department by identifying member and operational needs; ensures the management of work assignment completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies. Gains cross-functional support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress, and fosters resolution of escalated issues. Communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; prioritizes and distributes resources. Removes obstacles that impact performance; guides performance and develops contingency plans accordingly; ensures teams accomplish business objectives.
• Leads training and regulatory awareness by: identifying training outcome priorities, developing overall plans for, and may assist in the strategic development of training and orientation of newly appointed physician leaders for effective oversight and management of their departments credentialing, proctoring, privileging and reappointment processes; developing strategies and relationships to efficiently convey informational/educational documents (newsletters, memos) to communicate critical information regarding organizational programs and policies; enabling collaborations with interorganizational key stakeholders, both internal and external, to ensure appropriate awareness of key issues and decision-making; removing barriers to leadership meetings aimed at developing on-boarding processes (orientation, training activities) and alignment to education requirements; developing applicable governing documents (bylaws, rules and regulations/policies and procedures) that support and direct organizational practices and ensure compliance; and providing consultation on the interpretation, interaction, and implementation of current policies, regulations, and legislation and advices on the current climate and potential changes which may have long term effects on business operations.
• Ensures quality assurance, improvement, and resolution by: prioritizing organizational-wide the evaluation of practitioner sanctions, complaints, and adverse data to ensure compliance; conducting strategic planning to drive ongoing assessments of governing documents (e.g., bylaws/rules and regulations/policies and procedures) to ensure continuous compliance; partnering across organizations to support surveys and audits of credentialing entities (e.g., CMOs, delegates and health plans for NCQA); driving organization-wide priorities on efficient and cost-effective due process that complies with internal fair hearing and appeals policies and external legal and regulatory requirements; briefing facility leadership on, holding accountability for responses to, and may report high-impact adverse actions/issues (e.g., sanctions and complaints) taken against a practitioner/provider in accordance with applicable law and contractual requirements; and setting standards for consistent and accurate review of data between different departments, and monitoring of credentialing and contracting.
• Directs the provider enrollment process by: aligning standards and directing detailed and thorough review of the information used to submit the enrollment applications; developing strategies for timely data and applications to the contracted and government payors in a manner commensurate with their expectations, policies and accreditation standards; and collaborating with internal groups to progress and troubleshooting enrollment status to all stakeholders in a clear and timely manner.
• Leads primary source verification and management by: overseeing the management of the primary source vendor/relationships to ensure accessibility to information and resolve high-impact and complex issues with vendor information; leading strategic development, suggesting additions and improvements to organizational objectives, and outlining timelines for the review process of applications, primary source verifications, and sources provided to identify potential discrepancies and recognize adverse information; directing progress of and removing barriers to enable the verification and documentation of expirables using acceptable verification sources to ensure compliance with accreditation and regulatory standards; and establishing guidelines for processing and enabling relationships for external queries regarding practitioners status.
• Oversees delegation activities by: regularly collaborating with external/internal leaders, participating in the development strategies for adherence during development of corrective action plans, and evaluating gaps or breach of delegated credentialing agreements for potential and existing delegates; overseeing the facilitation of mutual agreement and amendments as needed, obtaining of signatures, and maintaining of Delegated Credentialing Agreements; setting expectations for the conducting of and overseeing pre-assessment, annual site visits, and/or electronic assessments to validate credentialing information; and leading collaborations with State Standardization and Audit teams (e.g., Washington Credentialing Standardization Group Shared Delegation Audit Team, ICE) on shared delegation audits.
• Leads database management by: developing and maintaining updated department guidelines in collaboration with internal leaders and KP priorities for the computerized data base of physician data for use in the credentialling and appointment process.
• Applies and ensures control and application of data systems by: forecasting future needs for the maintenance data structures, system functions, creations of workflows, portal management and managing the access and controls of data; defining standards for auditing, assessing, procuring, implementing, effectively utilizing, and maintaining practitioner/provider credentialing and delegated processes and information systems (e.g., files, reports, minutes, databases); and establishing guidelines for reviewing, evaluating, determining improvements to processes for implementation (e.g., electronic board memos) to ensure long-term compliance.
• Oversees data management and analyses by: directing teams to ensure efficient file completion, conduct privileging analyses, and verify privileging to the appropriate specialty/facility, based on data; and assisting the development and leading implementation of tools and policies to support knowledge management, record-keeping, and internal and external communication.
• Oversees credentialing and privileging maintenance and management by: overseeing and consulting on complex cases for alignment with guidelines and requirements for evaluation of application and supporting documents for completeness and to determine applicants initial eligibility for membership/participation; determining expectations for interactions with and information dissemination to practitioner during application process; overseeing and leading the evaluation, presentation, escalation follow-up of complex and intricate practitioner-specific data (e.g., Board Reports, Delegation reports) to decision-making bodies and developing process improvements, as needed; Establishing guidelines for initial or reappointment/re-credentialing for eligible practitioners for accuracy; leading definition of credentialing and privileging processes for all practitioners/providers; and leading facilitation of internal (e.g., interdisciplinary/scope of practice, medical executives) and supporting the facilitation of external committees (e.g., contracted facilities, state), projects, and relevant initiatives to implement change and to move QA initiatives forward.