Director Medical Staff Services

Do you have the career opportunities as a(an) Director Medical Staff Services you want with your current employer? We have an exciting opportunity for you to join Timpanogos Regional Hospital which is part of the nation's leading provider of healthcare services, HCA Healthcare.

Job Summary and Qualifications

The Facility director of Medical Staff Services assists the Division AVP Medical Staff Services with implementation of and compliance with credentialing initiatives/processes. The incumbent is expected to maintain a working knowledge of applicable HCA Healthcare and Parallon Credentialing Processing Center (CPC) policies, accreditation standards and regulations associated with medical staff services, and play a key role in the integration of HCA Clinical Strategies and HCA systems.

RESPONSIBILITIES & JOB FUNCTIONS

 1. Leadership

a. Provide management, support and guidance to facility and medical staff leadership

b. Create a collaborative team environment with an open communication culture

c. Take ownership by being decisive, problem solving, and abstaining from blame

d. Identify opportunities for change, drive change, and promote solutions

e. Be open to provide and receive objective feedback

f. Create strategic partnerships and collaborate facility stakeholders

g. Oversees management of facility Medical Staff Services operations

2. Medical Staff Operations

a. Develop self to be the facility subject matter expert on all things Medical Staff Services

b. Be the face of the facility MSO by attending scheduled medical staff meetings and facility meetings, being available for providers who stop by the MSO with questions, and interacting with medical staff on a regular basis

c. Manage correspondence between facility and medical staff members, not related to credentialing matters

d. Respond to all emails and voicemails promptly

e. Provide after-hours support for access related concerns from facility Administrator on Call (AOC)

f. Maintain the official emergency call schedule and records for call compensation payments

g. Coordinate the collection and handling of medical staff dues and other fees in accordance with Ethics & Compliance Policy TRE.001

h. Develop, maintain, and distribute medical staff governance documents (i.e. bylaws, rules & regulations, policies) and implement annual review process

i. Ensure current Medical Staff Bylaws, Credentials Policy, Organization Manual, and other pertinent medical staff policies are current on the facility intranet and external website

j. Disseminate facility, division, and/or corporate policies to medical staff leadership for review and approval

k. Manage requests for medical staff observers, in accordance to policy

l. Manage requests for APP students, in accordance to policy

3. Meeting Management

a. Facilitate Medical Staff department and meetings (develop agendas, maintain meeting minutes, coordinate follow-up) for the following meetings:

i. Medical Staff department/service line meetings – quarterly

ii. Credentials Committee – monthly

iii. Medical Executive Committee – monthly

iv. Leadership Council – as needed

v. General Medical Staff meetings – annually

vi. Additional medical staff meetings as required by facility’s Medical Staff Organization Manual

1. 1. Participate in facility FECC meetings – quarterly
   2. Participate in facility Professional Practice Evaluation Committee meetings – monthly
   3. Participate in facility referral panel meetings – monthly

1. Credentialing & Privileging Tasks – Facility

a. Support and manage up the division centralized credentialing model

b. Serve as a liaison between facility administration and division credentialing team, communicating facility priorities

c. In partnership with CPC and Division credentialing team, communicate with providers and delegates to obtain missing or incomplete information.

d. Manage Type 2 flags at the facility

e. Analyze any available internal data and information for an assessment of qualifications and competencies for each RRFC to include in reappointment applications for facility review.

i. Volume

ii. Focused or ongoing professional practice evaluations (FPPE/OPPE), performance improvement, utilization patterns, peer review, or other performance information

f. Utilize “paper-lite” procedures to prepare applications (RFC, RRFC, RFINCP) for facility review

g. Monitor provider requests for changes of status, adding to appropriate credentialing reports, forwarding to Credentials Committee (CC), Medical Executive Committee (MEC), and Board of Trustees (BOT)

h. Facilitate review, assessment, and authenticated documentation of an evaluation of each application and request for clinical privileges by the department/section chair

i. Facilitate review, assessment and recommendations for each application and request for clinical privileges by the CC and MEC

j. Forward MEC recommendations to the Board of Trustees for approval

k. Forward BOT approvals to Division credentialing team to perform facility post-BOT processes

l. Verify applicant identity in accordance (referring to MSS-004)

m. In partnership with CPC and Division credentialing team, actively manage each provider’s expiring credentials in accordance with CPC-36 and MSS-003

n. Monitor iResponse records in accordance to HCA Information Sharing Policy

o. Facilitate development of eligibility criteria for each clinical privilege or grouping of clinical privileges that require the same qualifications and competencies

p. Assess the applicability and appropriateness of clinical privileges for each specialty through periodic review

q. Facilitate any required regulatory agency reporting of adverse actions taken against a practitioner’s medical staff membership or clinical privileges, as directed by division and facility leadership  

5. Medical Staff Education

a. Participate in new provider onboarding, in partnership with other key stakeholders

b. Facilitate annual orientation for new Medical Staff leaders, committee members and governing body

c. Provide annual education to administrators and department directors regarding CPC operations and MSSD operations, and privileging (including temporary and disaster privileging)

d. Manage and monitor provider annual education requirements related to credentialing and privileging  

1. Accreditation and Regulatory Compliance

a. Develop self to serve as the facility subject matter expert regarding relevant accreditation and regulatory requirements related to the medical staff

b. Notify the CPC, Division and corporate teams of any upcoming or ongoing surveys relative to credentialing, privileging and PPE/peer review activities and functions

c. Coordinate accreditation, regulatory, and any internal surveys relative to credentialing, privileging and peer review activities and functions

d. Respond to any accreditation and regulatory compliance citations or deficiencies by developing and implementing corrective action plans

e. Partnering with facility stakeholders, such as administration, department directors, quality, operating room staff, continually audit internal processes and databases to ensure providers are appropriately privileged for the services they are providing within the facility

7. Performance Improvement/Peer Review/Patient Safety

a. Coordinate with the facility’s quality department to facilitate focused professional practice evaluation (FPPE), and any related evaluation at the conclusion of FPPE or a period of provisional status

b. Coordinate with the facility’s quality department to facilitate ongoing professional practice evaluation (OPPE)

c. Coordinate with facility leadership in the conduct of internal and external peer reviews

d. Complete a summary of FPPE, OPPE, and peer review results for evaluation by medical staff leaders as part of the R-RFC process, and ongoing as required by policy

e. Monitor and process concerns related to medical staff professional conduct, in accordance to Medical Staff Professionalism Policy

f. Monitor and process concerns related to medical staff health issues, in accordance to Practitioner Health Policy

8. Ethics & Compliance

a. Partnering with ECO, ensure tokens of appreciation and gifts provided to members of the medical staff are appropriately logged on the Business Courtesy Log, in accordance with Ethics & Compliance Policies LL.022, EC.005, EC.006, and EC.008

b. In accordance with Ethics & Compliance Policy EC.023, and in coordination with the facility’s ECO, submit a Reportable Issue report for any instances of a practitioner providing patient care within the facility without a legally required credential (e.g., license, DEA), or while under a Federal or state sanction, or without having current, approved clinical privileges

c. Routinely monitor pertinent Ethics & Compliance Policies and Procedures

9. National Practitioner Data Bank (NPDB)

a. Manage and maintain the NPDB account as the Data Bank Administrator

b. In collaboration with the facility’s Operations Counsel and appropriate facility leaders, submit reports to the NPDB as required by Federal law

c. Manage and respond to any requests for information made as the result of a NPDB report

d. Coordinate the completion of the NPDB’s Attestation by the facility’s Attesting Official at the time of renewal of the facility’s registration with NPDB

10. Miscellaneous

a. Attend scheduled 1:1 with supervisor

b. Meet with facility CEO/CMO on a regular basis

c. Attend Mountain Division Facility Manager/Director meetings – scheduled as needed (Webcam required)

d. Attend Mountain Division Medical Staff meetings – monthly (Webcam required)

e. Attend scheduled meetings with CPC Client Support Manager – monthly (Webcam required)

f. Work scheduled hours and communicate any changes to supervisor

g. Appropriately manage Paid Time Off (PTO), communicating with supervisor and appropriate facility leadership

h. Collaborate with facility and division leadership on miscellaneous projects as needed

i. Collaborate with division leaders on pertinent projects as needed

j. Other duties as assigned

HCA HEALTHCARE SYSTEM COORDINATION AND COLLABORATION

1. Attend initial orientation from the CPC and HCA’s Professional Practice Advancement department

2. Maintain an acute awareness and accurate interpretation of the HCA Healthcare credentialing policies and procedures

3. Read and be familiar with the HCA Healthcare Model Medical Staff Governance Documents (e.g., bylaws, credentials policy and organization manual), the PPE Manuals, and other model medical staff policies

4. Read and be familiar with facility Medical Staff Governance Documents (e.g., bylaws, credentials policy) to understand where they may differ from the HCA Healthcare models

5. Read and act on announcements and alerts from the Division leadership, Corporate Escalations, CPC Client Support Manager, and/or CPC Compliance, including:

i. Expirable credentials notifications

ii. Dynamic flag alerts

iii. Notices of changes or updates to Cactus, or CPC procedures

6. Read and act on the information from HCA’s Professional Practice Advancement department (e.g., Answer of the Week, Important Updates, and other announcements)

7. Participate in monthly ‘It Takes a Village’ calls

8. Participate in quarterly ‘Knowledge Bits’ calls

KNOWLEDGE, SKILLS AND ABILITIES: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required.

1. Respectful communication at all levels, in all interactions, being honest, open, and polite
2. Ability to establish and maintain long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations
3. Ability to work effectively with facility colleagues, physicians, and external parties
4. Ability to work independently and under pressure to follow through on issues
5. Excellent organization skills with attention to details
6. Analytical and problem-solving skills

7. Reasoning skills:

a. Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists

b. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form

8. Language skills:

a. Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations

b. Ability to write reports, business correspondence, and procedure manuals

c. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public

9. Basic computer skills: Microsoft Office (Outlook, Word, Excel, OneNote, PowerPoint, Edge, and OneDrive), Google Chrome, and Webex

10. Credentialing computer skills: CACTUS - ability to retrieve requested information through knowledge of queries and reports

11. Demonstrate knowledge of relevant laws, policies, regulations, and standards affecting credentialing decisions and interpretations, including confidentiality of privileged information gained as a result of job functions

12. Knowledge of medical terminology

13. Ability to perform basic mathematical calculations, balance and reconcile figures, compile statistics; punctuate properly, spell correctly and transcribe accurately

What qualifications you will need:

EDUCATION:Bachelor’s degree in healthcare management, business, or related field of study required.

Please note: A combination of 10 years of credentialing experience and single certification or a combination of 7 years of experience and dual certification is equivalent to a degree.

CERTIFICATION: Certified Professional Medical Services Management (CPMSM) and/or Certified Provider Credentialing Specialist (CPCS) – can be obtained within 1 year of start

EXPERIENCE: Minimum of 5 years of credentialing experience in an acute care hospital or CVO setting. Minimum of 3 years supervisory/management experience.

Benefits

Timpanogos Regional Hospital, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive benefits for medical, prescription drug, dental, vision, behavioral health and telemedicine services
• Wellbeing support, including free counseling and referral services
• Time away from work programs for paid time off, paid family leave, long- and short-term disability coverage and leaves of absence
• Savings and retirement resources, including a 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service), Employee Stock Purchase Plan, flexible spending accounts, preferred banking partnerships, retirement readiness tools, rollover support and financial wellbeing counseling
• Education support through tuition assistance, student loan assistance, certification support, dependent scholarships and a partnership with Galen College of Nursing
• Additional benefits for fertility and family building, adoption assistance, life insurance, supplemental health protection plans, auto and home insurance, legal counseling, identity theft protection and consumer discounts

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

HCA’s Mountain Division offers careers within 11 respected and integrated hospitals within Utah, Idaho and Alaska. While each site is unique in location, size, and community, all Mountain Division facilities share commonalities of compassion, patient-focused, quality care and collaborative teamwork. We know that together, we’re greater. We know that what makes us better makes our patients better. That’s why our facilities consistently receive national recognition for top quality and exceptional safety.

HCA’s Mountain Division hospitals are part of HCA Healthcare - a network of more than 300 affiliate hospitals, outpatient centers and business offices across the country – offering employees the opportunity for travel and relocation. HCA facilities are all about caring for people, and that care extends to patients, families and employees.

HCA Healthcare has been recognized as one of the World’s Most Ethical Companies® by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

"Bricks and mortar do not make a hospital. People do."- Dr. Thomas Frist, Sr.
HCA Healthcare Co-Founder

If you are looking for an opportunity that provides satisfaction and personal growth, we encourage you to apply for our Director Medical Staff Services opening. We promptly review all applications. Highly qualified candidates will be contacted for interviews. Unlock the possibilities and apply today!

We are an equal opportunity employer. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.