Responsible for the overall management of the medical staff services functions, including staffing, confidential practitioner database administration, survey preparation/coordination, credentialing, privileging, bylaws, rules and regulations, policies, procedures, focused and ongoing professional practice evaluation, committees and communications, CME, GME.
- Plans, directs, manages and monitors the day-to-day work activities of the Medical Staff Office, CME and GME, including budget management, workplace safety, and equipment management.
- Manages thecredentialing/recredentialing, proctoring, privileging and reappointment process for Licensed Independent Practitioners (LIPs) and Allied Health Professionals.Coordinates to ensure that credentials documents are complete prior to local approval process.
- Coordinates reappointment process to ensure that required data and documents for reappointment (OPPE, peer review, focused practice review) are produced and available for Medical Staff and committee review.
- Provides consultation and ensures compliance in regards to bylaws, regulatory, legal, and accreditation, medical staff standards. Participates in accreditation survey readiness activities (NCQA, Joint Commission, MediCal).
- Develop and implement systems and processes that meet requirements and adhere to Regional and Medical Center Credentialing Policies and Procedures in collaboration with internal stakeholders.
- Manages processes for assessing professional staff license and certification expirations, and implements suspension processes consistent with organizational policies.
- Acts as a liaison, technical advisor, and resource person for the professional and allied staff, administration within each site. Interprets requirements and disseminates information to all involved parties to assure necessary compliance, compatibility and continuous quality improvement of the credentialing process.
- Collaborates with the Chiefs of Medical Staff Departments and functions to ensure compliance with by laws. Provides orientation and training to newly appointed physician leaders for effective oversight and management of their departments credentialing, proctoring, privileging and reappointment processes.
- Coordinates with KP Legal counsel when legal actions require the production of credentialing and privileging documents.
- May provide managerial support and assistance for staff supporting Continuing Medical Education (CME) and Graduate Medical Education (GME) functions. Ensures systems and process are established to support ongoing regulatory compliance.
- Ensures systems and process are established to support ongoing compliance with ACGME standards.
- Coordinates the support for Medical Staff committees as assigned.
- Manages thehuman resource functions for hiring, training, evaluation and counseling staff, and assessing quality of service provided to key stakeholders.