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Director, Medical Staff Services/Credentialing

Company: The Chartis Group
Location: Pasadena
Posted on: June 9, 2021

Job Description:

Director, Medical Staff Services/Credentialing - The Greeley Company

About The Greeley Company

The Greeley Company is a leading provider of consulting, education, interim staffing, credentialing management, and external peer review to healthcare organizations nationwide. Headquartered in the greater Boston area, The Greeley Company has helped more than 1,000 healthcare organizations within the past three years address challenges related to regulatory compliance, credentialing and privileging, peer review, clinician burnout, bylaws and physician-hospital alignment.

The Greeley Company joined The Chartis Group in 2019. The Chartis Group is a comprehensive advisory and analytics services firm dedicated to the healthcare industry. With an unparalleled depth of expertise in strategic planning, operations and performance excellence, informatics and technology, and health analytics, Chartis helps leading academic medical centers, integrated delivery networks, children's hospitals, physician enterprises and healthcare service organizations achieve transformative results.

Across both Greeley and Chartis, we are lucky to have extraordinarily talented people working in our firm - all brought together around our unifying mission "to improve healthcare delivery", a shared dedication to our core values, and the emphasis we place on creating an environment that enriches the experiences of our clients, our colleagues and our communities.

Role Overview

The Director, Credence Business Unit, Medical Staff Services is responsible for directing and managing staff in order to provide the activities set forth in an agreed upon Statement of Work for the defined locations, functions, transition projects, and service level standards in accordance with The Greeley Company contract.

The Director, Medical Staff Services is the administrative liaison between the Medical Staff and Hospital Administration and the Board of Directors. Leadership accountability and application of leading industry practices is expected in managing practitioner competency systems; complying with policies, procedures and legal governance documents; support of Medical Staff Leadership and the organized medical staff; Medical Staff Services Department (MSSD) operations; hospital /health system interdepartmental collaboration. The Director is responsible for developing and implementing systems that support the Medical Staff and Hospital's mission and strategic plan. A key performance area is regulatory and accreditation knowledge and compliance.


  • Practitioner credentialing, privileging, and performance evaluation:
  • Plans, organizes and directs a comprehensive credentialing program
  • Directs all aspects of the credentialing functions for appointments and reappointments, expirables, privileges (disaster, temporary, modifications)
  • Collaborates with key stakeholders regarding practitioner's applications for membership and clinical privileges (e.g., senior management, medical staff leadership, recruitment, human resources, contract attorney, etc.)
  • Presentation of practitioner information for review and evaluation by medical staff leaders and support of follow-up on actions taken by the medical staff organization with regard to practitioner competency management
  • Designs, implements and manages an objective, criteria-based clinical privileging system
  • Ensures that clinical privileges performed are criteria-based and reflective of current services offered by the organization and encompasses licensed independent practitioners (LIPs) and advanced practice practitioners (APPs)
  • Remains up to date on new procedures, techniques and equipment relative to Medical Staff Services and general knowledge of procedures, techniques and equipment that may impact Medical Staff privileging
  • Controls the monitoring of procedure-established criteria to ensure that practitioners meet qualifications for eligibility to request and retain specific privileges
  • Works with other hospital personnel to ensure that practitioners' practice within the scope of their privileges
  • Interprets, develops and implements practices of all systems and functions to ensure continuous compliance with applicable regulatory agencies and accrediting bodies e.g., CMS, TJC, NCQA, etc.
  • Provides ongoing education to team and Medical Staff Leaders as necessary
  • Participates on hospital compliance teams and in regulatory and accreditation surveys, as needed
  • Collaborates with other hospital personnel regarding performance improvement data to help Medical Staff Leaders make informed decisions regarding practitioner competence
  • Collaborates with key staff on managing an ongoing reporting process that is accurate, timely and action driven
  • Works in conjunction with the Quality department on aspects related to the privileging functions relative to peer review and professional performance profiles
  • Support of Medical Staff Leadership:
  • Plans and manages an effective Medical Staff meeting management system
  • Directs meeting activities (agenda development, documentation, follow-up, communication)
  • Provides guidance on accreditation, regulatory issues, medico-legal implications, national standards of care, best practices, meeting outcomes and resolution
  • Plans and manages the administrative support to Medical StaffLeadership allowing them to effectively carry out their duties and responsibilities
  • Collaborates, develops and implements long and short-term goals
  • Manages processes related to investigative, disciplinary and legal proceedings, such as fair hearing and appeal
  • Technology
  • Responsible for the administration of the credentialing software system, including any upgrades or additional muddles purchased by facility
  • Protect the integrity and security of the database through the use of a data dictionary and performance of routine audits to ensure continuity accuracy, completeness and timeliness of the credentialing and privileging process
  • Supply practitioner demographic data per organizations needs; e.g. strategic planning, consideration of new services, practitioner directory
  • Operations, Financial and Quality Management
  • Promotes cost effective operations while maintaining acceptable service levels
  • Development and oversight of operational quality indicators that reflect meaningful measures of quality of services provided. These indicators are monitored on a scheduled basis and corrective action is instituted, when required
  • Assure that workflow, information systems and policies and procedures are current and appropriately maintained
  • Medical Staff Policies, Procedures and Documents
  • Control and direct the administrative support of Medical Staff governance documents
  • Ensure that all Medical Staff documents are current as applicable
  • Protect Medical Staff permanent records by managing a secure method of retention in accordance with the organization's retention policies and the department's policies
  • Understands, utilizes, and applies Greeley methodologies when applicable
  • Shares developed policies, procedures, documents, forms internally to support Greeley BPO (Credence) sites
  • MSSD Operations:
  • Directs and manages the strategic and daily activities of the department
  • Responsible for adequate staffing and efficient use of staffing resources
  • Establishes standards and analyzes work procedures that promote leading practices and champions innovation
  • Supports education, professionalism, practice-based learning and systems-based learning
  • Responsible for recruiting, training, mentoring, evaluating and disciplining departmental staff
  • Cultivates positive interpersonal relationships with the members of the Medical Staff, Medical Staff Leaders and Administrative and ancillary staff
  • Promotes ongoing education
  • Performs environmental surveillance to identify new sales opportunities
  • Medical Staff and Hospital Collaboration:
  • Directs the administrative interface with Medical Staff Leaders and Medical Staff organization and hospital administration, the Governing Body and hospital departments to assure and enhance effective relationships
  • Serves as a liaison between Medical Staff and Administrative Leadership
  • Serves as a liaison between Greeley and Administrative leadership as requested

Qualifications and Desired Skills

  • Minimum of 10 years' experience in an acute healthcare facility in a leadership position working with Medical Staff leaders, e.g. Medical Staff Services, Quality/Performance Improvement, Physician Recruitment, etc. is preferred.
  • Bachelor's degree required or equivalent in experience; Master's degree preferred, in healthcare administration or other applicable specialty or equivalent in experience is preferred.
  • Certified Professional Medical Services Management (CPMSM) required; additional certification in Certified Provider Credentialing Specialist (CPCS) is preferred.

At The Chartis Group, we pride ourselves on having a diverse workforce. We value and celebrate the uniqueness of individuals and the different perspectives they provide. We offer equal opportunity employment regardless of race, color, religion, gender identity or expression, sexual orientation, national origin, genetics, disability status, age, marital status, or protected veteran status.

Atlanta | Boston | Chicago | Minneapolis | New York | San Francisco

Keywords: The Chartis Group, Pasadena , Director, Medical Staff Services/Credentialing, Other , Pasadena, California

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