1. Coordinate the credentialing activities of the Medical Staff and Allied Health Staff, in accordance with the Medical Staff Bylaws, Credentialing Policies and Procedures of The Christ Hospital (TCH) as well as the federal and state law, regulatory and accrediting agencies:
A. Upon receipt of applications (initial and reappointment), determine if application meets the criteria and whether to initiate the verification process and documentation, according to policies;
B. Initiate and prepare all required primary source documentation such as American Medical Association (AMA) and National Practitioner Data Bank (NPDB), etc; and follow-up as necessary with the providers.
C. Monitor information collection and perform cognitive analysis of all information received; evaluate adequacy and quality, pursue additional information as needed.
D. Coordinate, perform and maintain tracking system for process to ensure continuous processing of applications, reporting to Manager, as needed;
E. Upon completion of credentialing process, update all relevant files and listings, credentialing database per policies and procedures and file credentialing files accordingly; and ensure clinical privileges are available on-line for TCH staff to ensure providers are practicing within their scope of privileges.
F. Prepare written notification of Board action to appropriate personnel / practitioners.
G. Initiate Focused Professional Practice Evaluation and assist with the Ongoing Professional Practice Evaluation for practitioners according to policy and procedures.
H. Assist the department directors and/or section chiefs to establish criteria for privileging.
I. Initiate and maintain proctoring of applicants as required with required follow-up.
2. Provide administrative support to Credentials, General Staff and other Medical Staff committees and departments of TCH as directed:
A. Attend meetings;
B. Provide meeting minutes, and maintain meeting minutes history (three-ring binders and/or on shared drive of medical staff services);
C. Notify members of meetings;
D. Preparation of meeting agenda / handouts, and follow-up to include coordination of actions taken;
E. Provide coverage for Medical Executive Committee, and others, as directed.
3. Process requests for temporary privileges and monitor all follow-up, in accordance with policies and procedures:
A. Communicate relevant information to applicant and appropriate hospital personnel;
B. Distribute appropriate paperwork;
C. Establish and maintain necessary files.
4. Process requests for additional privileges and monitor all follow-up, in accordance with policies and procedures:
A. Upon receipt of additional privilege application, initiate the verification process and documentation, according to policies;
B. Initiate and prepare all required primary source documentation, including National Practitioner Data Bank (NPDB), etc; and follow-up as necessary with the providers.
C. Maintain tracking system for process to ensure continuous processing of applications, reporting to Manager, as needed;
D. Upon completion of credentialing process, update all relevant files and listings, credentialing database per policies and procedures and file credentialing files accordingly; ensure clinical privileges are available on-line for TCH staff to ensure providers are practicing within their scope of privileges.
E. Prepare written notification of Board action to appropriate personnel / practitioners.
F. Communicate relevant information to applicant and appropriate hospital personnel;
G. Distribute appropriate paperwork;
H. Establish and maintain necessary files.
I. Initiate FPPE for all additional privileges.
5. Process requests for one-time privileges, visiting physicians and/or student observers.
A. Initiate primary source verification if applicable.
B. Maintain tracking system for process to ensure continuous processing of applications, reporting to Manager, as needed;
C. Upon completion, obtain appropriate signatures for privileges;
D. Communicate relevant information to applicant and appropriate hospital personnel;
E. Distribute appropriate paperwork; and
F. Establish and maintain necessary files.
6. Coordinate verification of professional liability coverage, medical licensure, board certification, BLS, ACLS, ATLS, and/or NRP certifications and DEA certification, as required.
7. Obtain updated PPD and annual AHP evaluations.
8. Assist with the coordination of annual dues process.
9. Credentialing/Database management
A. Ensure the data entered into the credentialing database is done efficiently and accurately.
B. Handles confidential materials. Maintains medical staff credentialing files, both electronic and hard copy; keeping them in an order fashion and filing.
C. Assist with special credentialing projects.
10. Assists customers in the absence of the Credentialing Assistant and/or Administrative Assistant.
11. Assist with Joint Commission accreditation preparation, as necessary.
12. Assist with coordination of yearly on-call schedule preparation and coordination of Department Director election (every two years).
13. Coordinate preparation and distribution of new committee roster (every two years) and yearly master calendar.
14. Assist with verifications of medical staff membership and clinical privileges of providers from other healthcare facilities.
15. Assist in coordination of medical staff events and functions and other duties assigned.
