Position Summary

The Director of Medical Staff will oversee the administrative functions of the Aultman Health System that support the Medical Staff in fulfilling their duties and obligations. The Director of Medical Staff Services acts as a bridge between the medical staff and the hospital administration, ensuring that the medical staff can provide high-quality patient care in a compliant and efficient manner. The position is also responsible for maintaining the orderly operations of the Medical Staff Office and coordinating all Medical Staff events and functions, while upholding the mission and values of the Aultman Health System.

Areas of Oversight Summary

The Medical Staff Director will oversee all medical staff within the Aultman System.

Qualifications

Bachelors Degree Required Masters Degree Preferred 5 - 7 years experience in a medical staff services or credentialling. 3 years of management experience CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Services Management) preferred Certification from the National Association of Medical Staff Services as Certified Provider Credentialing Specialist (CPSC) and/or Certified Professional Medical Services Management (CPMSM) or ability to obtain within 1-3 years of hire. Must possess expert knowledge of Medical Staff Services procedures, medical terminology and Joint Commission Medical Staff Standards.

 

Skills

Strong communication. organizational, problem-solving, and interpersonal skills Strong analytical skills Strong problem-solving skills Ability to organize and manage complex projects and procedures simultaneously. Ability to implement new programs and procedures. Ability to interpret policies and procedures and apply standards consistently. Ability to work independently, exercise good judgment, and motivate others. Computer skills including Word, Excel, and Powerpoint. Manage multiple demands effectively

 

 

Responsibilities & Expectations

The Medical Staff Director provides administrative assistance to the medical staff, ensuring they have the necessary resources and support to perform their roles effectively. Manages the credentialing and privileging processes for physicians and other practitioners, ensuring they meet the required standards. The Medical Staff Director stays up-to-date on relevant regulations and standards (e.g., Joint Commission, Medicare, HIPAA) and ensures the hospital's medical staff functions comply with these requirements. Oversees the day-to-day operations of the Medical Staff Office, including managing staff, budgets, and resources. The Medical Staff Director facilitates communication and collaboration between the medical staff, hospital administration, and other departments. May be involved in quality improvement initiatives related to medical staff performance and patient care. Developing and implementing policies and procedures related to the medical staff. The Director provides administrative assistance to the Medical Staff, ensuring they can fulfill their duties as defined in the Medical Staff Bylaws. Communicate effectively and professionally Provide leadership, oversight, and development to Medical Staff Office staff Coordinates with the quality department to ensure facilitation of both Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE). Coordinate strategies for engaging physicians Coordinate, attend and scribe minutes for all monthly Medical Executive Committee & Medical Staff Quarterly Meetings Facilitate revisions to the Medical Staff Bylaws, Rules and Regs, core privileges and medical staff policies as necessary Organize and coordinate Medical Staff Events: Annual Medical Staff Leadership Summits Annual Medical Staff Holiday Party Annual Hippocrates Honor Society Induction Annual Doctors Day FunDocs Events Communicate information pertaining to hospital practice to Medical Staff Coordinate Physician Satisfaction Survey (applicable years) Oversee Medical Record Delinquency process Organize New Practitioner Orientation Develops and maintains all delegated credentialing agreements and credentialing sharing agreements between entities. Direct responsibility for hiring, training, evaluating, job description , mentoring and ongoing professional development of all Medical Staff Services staff. Directly responsible for time keeping of staff and maintaining staff schedules. Provide assistance and support to the Medical Staff Department Chairs/Vice Chairs, Medical Staff Leaders, and all Medical Staff members and Allied Health Staff. Develop complete, standardized, and efficient processes that meet the Bylaws and Rules & Regulations of the Medical Staff and the Standards of The Joint Commission, and government regulations. Prepares and participates in Joint Commission accreditation survey. Oversees all aspects of Credentialing process, including appointment, reappointment, and requests for new privileges. Ensures the process includes all necessary documentation, primary source verifications, and red flag identifications as required by the Joint Commission and CMS. Collaborates with Quality Department regarding ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) process. Develops, directs and maintains systems for the organization of the Medical Staff governance and committee structure, including committee charter development and maintenance, ensuring committee reporting and information flow through the appropriate reporting lines of the organization. Coordinates development or revisions of Delineation of Privileges Forms to ensure that all credentialing is a criteria-based system Directs the development, enhancement and maintenance of the credentialing database; assures accuracy of data entry; monitors critical data for analysis and coordinates functional report generation.

 

Department Responsibilities & Expectations

Promotes Aultman RESPECT values to foster a healthy work environment, while maintaining an environment of fairness and inclusivity. Abide and engage in the Aultman Leadership Promise, ACE. Act - Meet with staff monthly. Communicate - Share information. Engage - Include colleagues in change initiatives. Abide and engage in the Aultman Leadership Values. Live our Mission - Demonstrate and support our mission and values in our day-to-day leadership. Think Strategically - Understand and communicate the vision and strategy. Lead with Integrity - Earn and give trust by being direct, truthful and admitting when wrong. Expect Excellence - Focus, align and build effective teams by attracting and retaining top talent. Inspire to Make a Difference - Set personal examples of good work ethic and motivation. Achieve Success - Set goals and motivate the team toward greater commitment to those goals

 

Working Conditions

Work approximately 8 hours per shift. Primarily Day Shift, occasional evening and weekend coverage. Shifts are variable to volume of department. Rotation as needed. Lunch periods and breaks are coordinated with other staff members to maintain adequate coverage. Cross training to other areas in the department to provide coverage as needed.

 

Hazardous Exposure Category

 

Category III - Includes tasks that involve no exposure to blood, body fluids, or tissues and Category I tasks are not a condition of employment. The normal work routine involves no exposure to blood; body fluids or tissues (although situations can be imagined or hypothesized under which anyone anywhere might encounter potential exposure to body fluids.) Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency care or first aid or to be potentially exposed in some other way.

 

Physical Addendum

Demands

Frequency

Lifting 0-10 lbs

Occasional 10-33%

Lifting 10-20 lbs

Occasional 10-33%

Lifting 20-35 lbs

Never

Lifting 35-50 lbs

Never

Lifting 50-75 lbs

Never

Lifting 75-100 lbs

Never

Lifting over 100 lbs

Never

Forward Reaching

Occasional 10-33%

Overhead Reaching

Occasional 10-33%

Standing

Occasional 10-33%

Walking

Occasional 10-33%

Sitting

Continuous 66% of the day

Climbing

Never

Stairs/Ladder

Occasional 10-33%

Bending/Stooping

Occasional 10-33%

Twisting/Turning

Occasional 10-33%

Kneeling/Squatting

Occasional 10-33%

Crawling

Never

Pushing/Pulling 0-10 lbs

Occasional 10-33%

Pushing/Pulling 10-20 lbs

Occasional 10-33%

Pushing/Pulling 20-35 lbs

Never

Pushing/Pulling 35-50 lbs

Never

Pushing/Pulling 50-100 lbs

Never

Pushing/Pulling over 100 lbs

Never

Carrying 0-10 lbs

Occasional 10-33%

Carrying 10-20 lbs

Occasional 10-33%

Carrying 20-35 lbs

Never

Carrying 35-50 lbs

Never

Carrying 50-100 lbs

Never

Carrying over 100 lbs

Never

Grasping/repetitive sustained

Occasional 10-33%

Fine motor coordination

Continuous 66% of the day

Vision: Near/Far/Color

Continuous 66% of the day

Hearing: ordinary conversation/other

Continuous 66% of the day

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status. AultCare is an EEO/AA Employer M/F/Disability/Vet.

 

AultCare/AHS will provide reasonable accommodations to employees or applicants with disabilities, as defined by the Americans with Disabilities Act, who are otherwise qualified to safely perform the essential functions of the job, with or without accommodation, unless such accommodation would constitute an undue hardship on AultCare/AHS or poses a direct threat to the health and safety of the individual or others that cannot be sufficiently mitigated by reasonable accommodation. Any applicant or employee who requires an accommodation to perform the essential functions of his or her job or to enjoy equal benefits and privileges of employment should notify the Aultman Human Resource Department and request such an accommodation.