Facility: Spalding Medical Center

Job Summary:

This position manages operations of the multiple hospitals assigned; manages the department and committee process of the Medical Staff organization which includes all aspects of credentialing and all aspects of privileging; compliance with Medical Staff bylaws, policies, rules and regulations; subject matter expert support for the Medical Staff leadership of the assigned hospitals. The position requires maintaining an understanding and knowledge of compliance and regulatory law while providing direction to Medical Staff and hospital leadership. Ensures that services are provided according to established policies and procedures. Establishes professional relationships and connects with all interdependent departments regularly to maintain awareness of successes and opportunities. The position will provide training and mentorship to Medical Staff Coordinators.

Core Responsibilities and Essential Functions:

1. Medical Staff Operations a. Coordinates for all duties of Medical Staff committees and departments of assigned multiple hospitals. b. Operationalizes actions such as corrective actions including the Fair Hearing Process to include interviewing, action plan development, creation of ad hoc committees, correspondence and other communication in collaboration with Medical Staff Services leadership and the legal department. c. Subject matter expert support to Medical Staff leadership, members and the hospital teams. d. Liaison between the medical staff, administration and the legal department. e. Ensures all orientation, education and development of medical staff coordinators. f. Provides mentorship to Medical Staff Coordinators and Credentialing Coordinators. 2. Credentialing a. Approves primary source credentialing and verifies adherence to privileging criteria of all Medical Staff for assigned hospital organization to include disaster privileges. b. Validates appointment and reappointment process follows policy, standards and regulations as set by the by-laws, joint commission and state/federal agencies. c. Accountable for the preparation and content of the Medical Staff Services Board report for their hospital. d. Coordinates and reviews all practitioner analytics obtained during the application and reappointment process. e. Collaborates with Quality Improvement, Risk Management and Legal as needed. f. Submits all necessary reports and data to appropriate committees. 4. Training and Mentorship a. Identifies training needs and participates in the development of team members based on identified needs. b. Responsible for training new team members. c. Provides mentorship to team members to assist in their growth and development. 3. Regulatory Compliance and Continuous Survey Readiness a. Responsible for compliance with all appropriate regulatory body standards, state and regulatory requirements and procedures regarding organized medical staff and credentialing processes. b. Maintains subject matter expert level knowledge of Medical Staff Bylaws, rules and regulations, policies and procedures. c. Demonstrates knowledge of external accrediting standards as well as state and federal regulations regarding Medical Staff, credentialing and privileging. Ability to interpret those standards providing information to the Medical Staff and Administration. d. Identifies need and participates in the development and revision of documents to ensure compliance to any external regulatory body or based on internal need. Ensures appropriate process and procedures are followed to make needed changes. e. Oversight of the following duties for assigned hospital: development and distribution of monthly emergency call schedules per EMTALA, socializes and maintains all system wide medical staff documents, preparation and participation in survey activities from Joint Commission, State, CMS, etc. Performs other duties as assigned Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Required Minimum Education:

High school diploma High school graduate or equivalent required. Required or Associate's Degree in related field such as health information or healthcare administration Preferred or Bachelor's Degree in related field such as health information or healthcare administration Preferred

Required Minimum License(s) and Certification(s):

All certifications are required upon hire unless otherwise stated.

• CPCS - Cert Provider Credential Spec

Additional License(s) and Certification(s):

Required Minimum Experience:

Minimum 5 years 5 years as a medical staff services professional within a hospital setting required. Experience in an integrated multi-facility system and managed care environment preferred. Additionally, experience with state/federal regulatory requirements, accreditation standards, Joint Commission and other surveys preferred. Required

Required Minimum Skills:

Excellent verbal and written communication skill along with the ability to work with computer-based system for data entry and extraction. Knowledge of government payers and the basic principles of credentialing and privileging within a hospital environment. Ability to analyze file information and other data for compliance to a process or policy.