Credentialing / MSO Coordinator

About the role

For the past 85 years, Stephens County Hospital has been a trusted name in the community, striving for excellence and delivering professional and compassionate care. Our dedicated staff of approximately 475 employees has a heart for healthcare and realizes how precious the gift of good health can be. Stephens County Hospital is a 96-bed acute care hospital located in Toccoa, Georgia. We are nestled in the beautiful foothills of Northeast Georgia where our family-oriented community offers many cultural and civic opportunities as well as numerous outdoor activities.

Stephens County Hospital is a member of the Georgia Hospital Association, American Hospital Association and Georgia Alliance of Community Hospitals. Stephens County Hospital is fully accredited by the Joint Commission, the nation’s premier healthcare monitoring agency.

Responsibilities

• Absorbs and supports changes in assignments without disrupting work or department.
• Willing to alter job procedures to accommodate the needs of others.
• Willing to alter scheduled work time as needed.
• Volunteers to accept additional duties.
• Works positively with others.
• Supports manager/supervisor.
• Acts to promote harmonious work relationships and contributes to effective teamwork in the department and hospital.
• Completes assignments and routine job functions on time without reminders (to include annual health update, etc.).
• Volunteers regularly for CQI teams.
• Deals courteously and tactfully with others displaying understanding and concern: patients, visitors, co-workers, physicians, public-at-large, vendors.
• Attends monthly staff meetings and offers constructive input.
• Processes privilege requests per the time period specified in the Medical Staff Bylaws.
• Assures privileges requested are currently available at SCH and are necessary.
• Assures a comprehensive evaluation of the practitioner’s professional experience includes patient care, medical/clinical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism and systems based practices.
• Assures education and relevant training is verified via an original source when possible according to Joint Commission standards. When not possible, utilizes only reliable secondary sources.
• Assures that licenses are verified prior to granting of initial privileges, re-privileging and prior to license expiration.
• Acts as a liaison between the officers of the Medical Staff and Hospital Administrator in granting of privileges.
• Maintains a database of DEA and malpractice insurance dates; contacts physicians and allied health professionals for updated information.
• Circulates notices of new privileges granted to include necessary demographic and privileging information required by various departments.
• Participates in The Joint Commission Survey Medical Staff Credentialing session each survey.
• Compiles physician performance information for presentation to the Medical Executive Committee in July and December to substantiate ongoing professional practice evaluation.
• Aggregates, analyzes and compares data to other peers in the same profession. Information is collected on abbreviation usage, unplanned trips to the OR, utilization statistics and patterns, obstetric data, postoperative complications, infections and core measure indicators.
• Processes reappointment applications per the time period specified in the Medical Staff Bylaws.
• Contacts other facilities for information to substantiate requests and competence for reappointment of low volume practitioners.
• Reviews information gathered during credentialing/recredentialing process and discusses potential problem areas with QI Director and Chief of Staff.
• Initiates and compiles physician practice indices in accordance with the reappointment process.
• Assures compliance with The Joint Commission Medical Staff standards.
• Maintains files of credentialing information in an organized manner.
• Works with the Medical Director of CME to establish a calendar of programs.
• Coordinates meals for programs with the dietary department and/or sponsoring agencies.
• Maintains a complete and accurate record of attendees, evaluations and programs offered.
• Coordinates logistics for programs.
• Develops flyers/notices of inservices and distributes to physicians.
• Attends the Surgical Service Committee each quarter with the Surgical Services Manager.
• Develops the meeting agenda for the Surgical Service Committee in coordination with the Surgical Services Manager and Chief of Surgery.
• Performs quarterly medical record reviews required for the Medical Staff performance improvement to include blood utilization/compliance, high risk/high volume procedures per criteria established by Surgery Service Committee, anesthesia cases to include conscious sedation and pre/post-operative diagnoses reviews.
• Assures that actions discussed at the Surgery Service Committee are followed up on at the next meeting or coordinates follow up after the meeting.
• Assures performance improvement data and core measure data is discussed at each Committee meeting.
• Affords assistance with the review of inpatient medical records for compliance with required core measures – pneumonia, congestive heart failure, acute MI and surgical care improvement project.
• Increases and maintains record reviews in accordance with the Data Specification Manual instructions and passes validation audits by the Georgia Medical Care Foundation.
• Affords assistance with the review of outpatient (ER and outpatient surgery) medical records for compliance with required core measures – chest pain/acute MI and surgical care improvement project.
• Ensures information from these reviews is entered in the CART program for submission to HERMES and QNET conduits.
• Investigates, corrects and resubmits any data transmission errors.
• Logs incident reports when received.
• Affords assistance in investigating incident reports to appropriate individuals.
• Schedules meetings and reserves space as needed.
• Sends meeting notices and agendas.
• Affords assistance in routing monthly calendars to appropriate individuals.
• Affords assistance in compiling and copying the necessary information for meetings.
• Maintains attendance records of physicians.
• Transcribes meeting minutes and correspondence.
• Organizes and enters Surgical Case information in a manner that can be reviewed by the QI Director and the Medical Director of the Laboratory.
• Performs quarterly data collection required for Medical Staff performance improvement.
• Designs forms to accommodate the collection of information.
• Designs databases and spreadsheets to facilitate the collection and reporting of information.
• Typing documents and correspondence for the department.
• Maintains adequate supplies for the department.
• Filings information in an organized manner.
• Routinely culls files of old information or information that can be condensed into another format.
• Microfilms records.
• Photocopies, faxes and routes mail.
• Enters data into computer files on a routine basis.
• Develops charts and graphs to provide information for Medical Staff.

Qualifications

• Accepts and supports change in assignments without disruption in work/department.
• Willing to alter, if possible, job procedures to accommodate the needs of others.
• Willing to alter scheduled work time as needed.
• Volunteers to accept additional duties.
• Works positively with others.
• Supports manager/supervisor.
• Acts to promote harmonious work relationships and contributes to effective teamwork in the department and hospital.
• Completes assignments and routine job functions on time without reminders (to include annual health update, etc.).
• Volunteers regularly for CQI teams.
• Deals courteously and tactfully with others displaying understanding and concern: patients, visitors, co-workers, physicians, public-at-large, vendors.
• Attends monthly staff meetings and offers constructive input.
• Processes privilege requests per the time period specified in the Medical Staff Bylaws.
• Assures privileges requested are currently available at SCH and are necessary.
• Assures a comprehensive evaluation of the practitioner’s professional experience includes patient care, medical/clinical knowledge, practice based learning and improvement, interpersonal and communication skills, professionalism and systems based practices.
• Assures education and relevant training is verified via an original source when possible according to Joint Commission standards. When not possible, utilizes only reliable secondary sources.
• Assures that licenses are verified prior to granting of initial privileges, re-privileging and prior to license expiration.
• Acts as a liaison between the officers of the Medical Staff and Hospital Administrator in granting of privileges.
• Maintains a database of DEA and malpractice insurance dates; contacts physicians and allied health professionals for updated information.
• Circulates notices of new privileges granted to include necessary demographic and privileging information required by various departments.
• Participates in The Joint Commission Survey Medical Staff Credentialing session each survey.
• Compiles physician performance information for presentation to the Medical Executive Committee in July and December to substantiate ongoing professional practice evaluation.
• Aggregates, analyzes and compares data to other peers in the same profession. Information is collected on abbreviation usage, unplanned trips to the OR, utilization statistics and patterns, obstetric data, postoperative complications, infections and core measure indicators.
• Processes reappointment applications per the time period specified in the Medical Staff Bylaws.
• Contacts other facilities for information to substantiate requests and competence for reappointment of low volume practitioners.
• Reviews information gathered during credentialing/recredentialing process and discusses potential problem areas with QI Director and Chief of Staff.
• Initiates and compiles physician practice indices in accordance with the reappointment process.
• Assures compliance with The Joint Commission Medical Staff standards.
• Maintains files of credentialing information in an organized manner.
• Works with the Medical Director of CME to establish a calendar of programs.
• Coordinates meals for programs with the dietary department and/or sponsoring agencies.
• Maintains a complete and accurate record of attendees, evaluations and programs offered.
• Coordinates logistics for programs.
• Develops flyers/notices of inservices and distributes to physicians.
• Attends the Surgical Service Committee each quarter with the Surgical Services Manager.
• Develops the meeting agenda for the Surgical Service Committee in coordination with the Surgical Services Manager and Chief of Surgery.
• Performs quarterly medical record reviews required for the Medical Staff performance improvement to include blood utilization/compliance, high risk/high volume procedures per criteria established by Surgery Service Committee, anesthesia cases to include conscious sedation and pre/post-operative diagnoses reviews.
• Assures that actions discussed at the Surgery Service Committee are followed up on at the next meeting or coordinates follow up after the meeting.
• Assures performance improvement data and core measure data is discussed at each Committee meeting.
• Affords assistance with the review of inpatient medical records for compliance with required core measures – pneumonia, congestive heart failure, acute MI and surgical care improvement project.
• Increases and maintains record reviews in accordance with the Data Specification Manual instructions and passes validation audits by the Georgia Medical Care Foundation.
• Affords assistance with the review of outpatient (ER and outpatient surgery) medical records for compliance with required core measures – chest pain/acute MI and surgical care improvement project.
• Ensures information from these reviews is entered in the CART program for submission to HERMES and QNET conduits.
• Investigates, corrects and resubmits any data transmission errors.
• Logs incident reports when received.
• Affords assistance in investigating incident reports to appropriate individuals.
• Schedules meetings and reserves space as needed.
• Sends meeting notices and agendas.
• Affords assistance in routing monthly calendars to appropriate individuals.
• Affords assistance in compiling and copying the necessary information for meetings.
• Maintains attendance records of physicians.
• Transcribes meeting minutes and correspondence.
• Organizes and enters Surgical Case information in a manner that can be