Director Med Staff Services

This position is incentive eligible.

About the role

At HCA Healthcare, we are committed to caring for patients with purpose and integrity. Join our team as a Director of Medical Staff Services at Catholic Medical Center and play a key role in the integration of HCA Clinical Strategies and HCA systems.

Responsibilities

• Medical Staff Administration
  • Develop facility credentialing policies in accordance with accreditation/regulatory standards, HCA Healthcare policies, and medical staff bylaws.
  • Facilitate meetings (develop agendas, maintain meeting minutes, coordinate follow-up) for the following committees:
    • Medical Executive Committee
    • Credentials Committee
    • Leadership Council
    • Other Medical Staff Committee, Department, and Service Meetings as assigned.
  • Coordinate the work of the Leadership Council in matters related to practitioner health and professional conduct, and support functions for continued monitoring.
  • Maintain the official emergency call schedule and records for call compensation payments.
  • Manage correspondence between facility and individual medical staff members.
  • Provide support functions to medical staff officers in performance of their duties.
  • Prepare credentialing reports for medical staff leaders, committees, and the governing body.
  • Develop, maintain, and distribute medical staff governance documents (e.g., bylaws, rules & regulations, policies) and implement annual review process.
  • Serve as the primary liaison between the facility, Division Medical Staff Services, and the Credentialing Processing Center (CPC).
  • Ensure all facility non-privileged practitioner processes comply with Ethics & Compliance Policy CSG.QS.002, including updates to the electronic Security Access Form (eSAF) Tool.
  • Ensure tokens of appreciation and gifts provided to medical staff are reported to the Ethics & Compliance Officer (ECO) in accordance with relevant policies.
  • Coordinate the collection and handling of medical staff dues and other fees, if applicable.
  • Update Meditech Practitioner Dictionary/Database to align with practitioner data in Cactus.
  • Participate in planning for future medical staff recruitment.
  • Develop annual business plan and supervise annual budget if assigned.
  • Edit and write a medical staff newsletter or maintain the medical staff-related section of the facility website.
  • Maintain and distribute a master medical staff calendar of activities.
  • Manage the medical staff hotline.
• Medical Staff Education
  • Facilitate orientation for new medical staff members in partnership with key stakeholders.
  • Facilitate orientation for new officers, committee members, and governing body.
  • Provide education to administrators and department directors regarding CPC operations, privileging, and non-privileged practitioner credentialing.
  • Facilitate continuing medical education (CME) programs offered through the facility.
• Accreditation and Regulatory Compliance
  • Serve as the facility’s subject matter expert regarding relevant accreditation and regulatory requirements related to the medical staff.
  • Notify the CPC, Division MSS, and corporate teams of any upcoming or ongoing surveys related to credentialing, privileging, and peer review activities.
  • Coordinate accreditation, regulatory, and internal surveys related to credentialing, privileging, and peer review activities.
  • Respond to accreditation and regulatory compliance citations or deficiencies by developing and implementing corrective action plans.
• Facility-based Credentialing Tasks
  • Apply the credentials evaluation process uniformly to all applications to ensure compliance with internal credentialing procedures.
  • Process applications and re-applications received from the CPC that have a flag in accordance with CPC-32 and MSS-002 policy.
  • Verify applicant identity in accordance with MSS-004.
  • Forward updated information received from a practitioner to the Division MSS/CPC in a timely manner.
  • Compile and analyze internal data for an assessment of qualifications and competencies for each re-application, including:
    • CME credits in accordance with medical staff bylaws.
    • Volume, FPPE/OPPE, performance improvement, utilization patterns, peer review, or other performance information.
  • Facilitate review, assessment, and documentation of each application and request for clinical privileges by the section chief/department chairman.
  • Facilitate review and recommendations by the Credentials Committee and Medical Executive Committee.
  • Utilize “paper-lite” procedures to facilitate medical staff reviews and maximize use of iObserver functionality in Cactus.
  • Summarize and prepare credentialing information for the board’s review and decisions.
  • Actively manage each practitioner’s expiring credentials in accordance with CPC-36 and MSS-003.
  • Update Cactus and MEDITECH systems to reflect all board actions on a practitioner’s application, including resignations, terminations, LOAs, denials, or withdrawals.
  • Manage and archive files according to HCA Healthcare and facility procedures and accreditation/regulatory standards.
• Privileging
  • Facilitate development of eligibility criteria for each clinical privilege or grouping of clinical privileges.
  • Facilitate the review of requests for clinical privileges using approved eligibility criteria.
  • Assess the applicability and appropriateness of clinical privileges for each specialty through periodic review.
  • Maintain up-to-date privilege content within the Visual Cactus system and MEDITECH Practitioner Dictionary/Database.
  • Update the electronic Security Access Form (eSAF) Tool to align with practitioner’s membership status and/or clinical privileges.
  • Coordinate access by authorized facility staff to credentialing information as needed through iPrivileges or iPharmacy portal.
  • Facilitate regulatory agency reporting of adverse actions taken against a practitioner’s medical staff membership or clinical privileges.
• Performance Improvement/Peer Review/Patient Safety
  • Coordinate with the facility’s quality department to facilitate focused professional practice evaluation (FPPE) and related evaluations.
  • Coordinate ongoing professional practice evaluation (OPPE).
  • Coordinate internal and external peer reviews with facility leadership.
  • Complete summaries of FPPE, OPPE, and peer review results for evaluation by medical staff leaders.
  • Collaborate with the CPC to identify critical MSSD performance benchmarks, measure performance, and take action to improve when needed.
  • Coordinate with the facility’s Patient Safety Officer in the medical staff review of occurrence reports, patient complaints, close call data, and SPAE reports.
  • Coordinate medical staff participation in HCA Healthcare Patient Safety Organization (PSO) activities, including handling Patient Safety Work Product (PSWP).
• Risk Management
  • Coordinate with the risk manager to review and evaluate an applicant’s claims history and National Practitioner Data Bank reports.
  • Ensure timely and proper notification of the risk manager regarding possible malpractice or other liability concerns.
  • Coordinate all medical staff disciplinary actions (e.g., formal investigations, professional review actions).
  • Facilitate due process in accordance with the facility’s fair hearing and appeals policy and legal/regulatory requirements.
  • Submit a Reportable Issue report for any instances of a practitioner providing patient care without legally required credentials or while under sanction.
• National Practitioner Data Bank (NPDB)
  • Manage and maintain the NPDB account as the Data Bank Administrator.
  • Submit reports to the NPDB as required by Federal law in collaboration with facility Operations Counsel and leaders.
  • Manage and respond to requests for information resulting from a NPDB report.
  • Coordinate the completion of the NPDB’s Attestation by the facility’s Attesting Official.

Benefits

Catholic Medical Center offers a total rewards package that supports the health, life, career, and retirement of our colleagues. Available plans and programs include:

• Comprehensive medical coverage with low copay or no-cost services, including prescription drug and behavioral health coverage, free telemedicine services, and free AirMed medical transportation.
• Dental and vision benefits, life and disability coverage, flexible spending accounts, and supplemental health protection plans (accident, critical illness, hospital indemnity).
• Auto and home insurance, identity theft protection, legal counseling, and long-term care coverage.
• Moving assistance and pet insurance.
• Free counseling services and resources for emotional, physical, and financial wellbeing.
• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service).
• Employee Stock Purchase Plan with 10% off HCA Healthcare stock.
• Family support through fertility and family-building benefits with Progyny and adoption assistance.
• Referral services for child, elder, and pet care, home and auto repair, event planning, and more.
• Consumer discounts through Abenity and other programs.
• Retirement readiness, rollover assistance services, and preferred banking partnerships.
• Education assistance (tuition, student loan, certification support, dependent scholarships).
• Colleague recognition program.
• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage, and leaves of absence).
• Employee Health Assistance Fund offering free employee-only coverage to full-time and part-time colleagues based on income.

Note: Eligibility for benefits may vary by location.