Manager, Medical Staff Services

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  • Oakland, CA
  • Highland General Hospital
  • Medical Staff Office
  • Full Time - Varies
  • Management
  • Req #: 26594-17605
  • Posted: April 15, 2020
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SUMMARY: Responsible for advanced credentialing functions pertaining to Medical Staff and Allied Health Professional as set forth in The Joint Commission (TJC), State Regulations and CMS Regulations; coordinates the initial credentialing and re-credentialing process; ensures the credentialing process complies with organizational and regulatory standards; responsible for oversight activities within the Medical Staff Services Department to include management of credentialing information, coordination of correspondence and interactions with providers and external organizations.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level.  Not all duties listed are necessarily performed by each individual in the classification.

1.  Supervises staff and manages employee performance; provides on-going performance feedback, addresses problems, orients and trains employees, verifies competency and identifies and suggests way to develop skills; monitors workflow.

2.  Plans, organizes and directs the day to day operations of Medical Staff Services for San Leandro Hospital and Alameda Hospital including staff supervision, verification of physician credentials, communications with physicians, hospitals and various agencies involved with medical staff services.

3.  Accountable for establishing, contributing, and implementation of standards applicable to medical staff members relating to credentialing and administrative functions for responsible hospital and system.

4.  Complies with all regulatory standards, providing consultative expertise to the medical staff and hospital leadership on options and permissible actions in order to meet those standards.

5.  Assists management in preparing for regulatory bodies (TJC, NCQA, CMS, federal and state) and health plan audits.  Participates in the continuous readiness program for TJC and completes the annual PPR.

6.  Maintains, develops and revises policies and procedures to comply with medical staff bylaws, hospital bylaws, managed care policies, regulatory bodies (TJC, NCQA, CMS, federal and state).

7.  Maintains knowledge of accreditation, licensing, and educational requirements; assists in implementation.

8.  Assists Medical Staff Officers in the pursuit of their responsibilities as defined in the Medical Staff Bylaws, and Rules/Regulations.

9.  Provides a collegial environment which fosters teamwork both within the medical staff office, with other members of the medical staff service department and medical staff members of hospital.

10. Ensure all provider credentials meet the requirements as outlined by hospital medical staff bylaws.

11. Assist in the development of the system medical staff service budget; monitor operating budget and staffing level for consistency with departmental goals.

12. Coordinates transmittal of complete credentials file through the various review committees.

13. Collaborates with Quality and Physician Leaders to develop Departmental Professional Practice Evaluation (FPPE/OPPE) metrics to be used for evaluating the performance of practitioners.

14. Coordinates and maintains Medical Staff bank accounts; prepares reports for the Medical Staff Treasurer.

15. Facilitates Medical Executive Committees including agenda preparation, meeting minutes, performs follow-up as required and prepares reports to the Board of Trustees.

16. Assumes responsibility and accountability as custodian of records for all files, minutes, reports, etc., relative to the activity of the medical staff.

17. Performs other duties as assigned.


Required Education: Associate Degree.

Preferred Education: Bachelor's Degree from an accredited college or university, or other related field preferred.
equired Experience: Five years experience within Medical Staff environment in an acute care hospital.

Preferred Experience: Three year supervisory experience preferred; previous exposure to bargaining positions preferred.
Licenses/Certifications: Must be eligible to obtain National Association of Medical Staff Services; Certified Professional Medical Services Management (CPMSM) and/or Certified Provider Credentialing Specialist (CPCS) within one year of hire.


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