Job Objective:

Under the direction of the Chief Medical Officer (CMO), directs medical-administrative and medico-legal aspects of the Medical Staff organization; serves as an essential link between senior management and the Medical Staff to promote and enhance good communications and a positive working relationship.

Essential Duties and Responsibilities:

1. Establishes, contributes to and maintains continuity in the planning, development and implementation of standards applicable to Medical Staff members relating to credentialing, performance improvement and administrative functions.
2. Prepares, organizes and follow-ups in maintaining hospital accreditation and licensure with The Joint Commission and other regulatory requirements of governing agencies in accordance with established Medical Staff Bylaws as they relate to the Medical Staff organization and support services.
3. Establishes and maintains systems for the development and implementation of standards applicable to Medical Staff members related to credentialing, performance improvement and administrative functions.
4. Provides advice to Medical Staff, committee members and other healthcare professionals of ongoing proposed activities designed to assess physician performance, identify risks and recommend disciplinary options when appropriate.
5. Directs a comprehensive program of credentialing and re-credentialing of the Medical Staff and allied health professionals in accordance with Medical Staff Bylaws provisions with an emphasis on continuous performance improvement and focused and ongoing professional practice evaluation.
6. Supervises Medical Staff Assistant and other employees in the Department.
7. Provides consultation to Medical Staff leadership in the implementation of their duties in accordance with and as directed by the Medical Staff Bylaws and related manuals
8. Provides resources and support to the Medical Staff by providing support staff in the execution of all Medical Staff responsibilities in keeping with the Medical Staff Bylaws and related manuals
9. Responsible for development of Medical Executive Committee agenda as a collaborative effort with the Chief of Staff and/or CEO.
10. Responsible for recording and maintenance of all activities related to the functioning of the Medical Executive Committee and subsequent reporting of Medical Staff activities presented from the Medical Executive Committee to the Board of Directors.
11. Responsible/supervises preparation of all reports submitted to the Medical Executive Committee as required.
12. Responsible for preparation of Medical Executive Committee recommendations and associated documents for forwarding to the Board of Directors.
13. Acts as a liaison between the Medical Staff and other hospital departments/managers
14. Accepts/processes complaints filed against members of the Medical Staff and/or allied health professionals in a collaborative effort with Administration and the Performance Improvement Department
15. To be familiar with Peer Review Process CME Program and it’s requirements and supervise the Peer Review/CME Coordinator.

Non-Essential Duties:

• Other duties as assigned.

Knowledge, Skills and Abilities:

Knowledge

• Knowledge in Joint Commission credentialing procedures
• Knowledgeable of Medical Staff Bylaws, Medical Staff General Rules and Regulations, Departmental Rules and Regulations, Credentials Manual, Fair Hearing Plan and Medical Staff Organization and Functions Manual and provides support to the Medical Staff and advice for maintenance and revision of those documents whenever necessary
• Knowledge of medical terminology

Skills

• Strong computer skills and the ability to learn and use new software and technology
• Excellent written, verbal and presentation skills.
• Excellent interpersonal, organizational skills and detail orientation.
• Strong planning, organizing, managing, time management and interpersonal skills.
• Delegating and directing
• Planning and team building

Abilities

• Able to work under pressure to meet established goals and objectives.
• Able to anticipate and solve problems
• Ability to work autonomously.
• Ability to work with clients across all levels of the organization.
• Ability to learn and use new software and technology.
• Ability to work effectively and produce under tight deadlines and schedules.
• Ability to prioritize and work on multiple projects.

AVMC Values: All AVMC employees will effectively demonstrate these values:

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.

• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.

Management Competencies: All AVMC management (Supervisor, Manager, and Assistant Director) will effectively demonstrate these behaviors:

• Conflict Management
• Problem Solving
• Timely Decision Making
• Process Management
• Fairness to Direct Reports
• Hiring & Staffing
• Developing Direct Reports

Leadership Competencies: All AVMC Leadership (Executive Director, Vice President, and CEO) will effectively demonstrate these behaviors:

• Dealing w/ Ambiguity
• Interpersonal Savvy
• Organizational Agility
• Strategic Agility
• Drive for Results
• Perseverance

Education and Experience:

Education

• Associate’s Degree in Medical Staff Services or related field.
• Bachelor’s Degree preferred.

Experience

• Minimum of five years experience in a hospital setting, preferably in Medical Staff Services department

Required Licensure and/or Certifications:

• Certification by the National Association Medical Staff Services

AVMC Conduct/Compliance Expectations :

• Ability to adhere with AVMC Attendance and Punctuality Policy
• Ability to adhere with AVMC Leaves of Absence Policy
• Ability to adhere with AVMC Paid Time Off (PTO) Policy
• Ability to adhere to the department dress code
• Ability to organize work and establish priorities
• Ability to expand on own initiative in performance of duties
• Skill and ability to follow the telephone etiquette/standards
• Ability to function effectively under pressure and meet time parameters

• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC
• Ability to maintain the confidentiality of patient, hospital and department information
• Ability to adhere to safety rules and regulations
• Safely and effectively uses all equipment necessary to carry out duties
• Ability to interpret and function under hospital and department policies and procedures
• Conforms with required and appropriate accreditation and regulatory requirements
• Conforms with and supports hospital quality assurance and improvement guidelines
• Ability to participate effectively in department and hospital staff education
• Display a willingness to work as a team player
• Ability to give and support the highest level of patient/customer satisfaction at all times
• Supports and adheres to the values and mission statement established by the AVMC Board of Directors
• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
• Ability to follow the Code of Conduct

Physical Requirements and Working Conditions:

• Normal office environment.

A detailed description of the physical requirements of this job is maintained in the Employee Health Department .

NOTE: THE ABOVE STATEMENTS ARE INTENDED TO DESCRIBE THE GENERAL NATURE AND LEVEL OF WORK PERFORMED BY PEOPLE ASSIGNED TO THIS JOB. THIS DOCUMENT IS NOT INTENDED TO BE AN EXHAUSTIVE LIST OF ALL RESPONSIBILITIES, SKILLS, AND WORKING CONDITIONS FOR THE PERSONNEL SO CLASSIFIED.

Education

• Associate’s Degree in Medical Staff Services or related field.

Experience

• Minimum of five years experience in a hospital setting, preferably in Medical Staff Services department

Required Licensure and/or Certifications:

• Certification by the National Association Medical Staff Services