Medical Staff Services Coordinator

About the Role

The Medical Staff Coordinator serves as a resource to, and collaborates with, Chief of Staff (COS)/Medical Director, Medical Staff, Advanced Practice Professionals (APP) and hospital administration. Responsible for maintaining and monitoring the operational processes and Medical Staff governance functions of the office of Medical Staff. In collaboration with the Credentialing Verification Office (CVO), the Medical Staff Coordinator acts as a liaison between the CVO and the medical staff office, supporting the credentialing and privileging application process. The role requires maintaining strict confidentiality and ensuring compliance with organizational policies and accrediting and regulatory agencies.

Responsibilities

• Provider On/Off Boarding and CVO Liaison
  • Coordinates requests for credentialing and privileges to CVO, including appointments, re-appointments, status changes, LOA, and other updates.
  • Coordinates the credential file from the CVO through the MEC and BOG approval process per Medical Staff Bylaws, including attending meetings of the Medical Committee of the Board of Governors.
  • Coordinates and collaborates with residency program directors, medical schools, and others to facilitate Fellow/Resident/Student/Observer rotations.
  • Processes residents and clinical fellows, performs review and analysis, identifies and follows up on missing items, and prepares files for review and recommendation by the Medical Staff.
  • Inputs fellow and resident information into the credentialing database (MD-Staff) unless otherwise assigned.
  • Coordinates fellow/resident/student/observer paperwork with affiliated facilities to ensure completion of all required documents before rotation start dates.
  • Coordinates performance reviews of Residents per the Medical Staff Bylaws.
  • Coordinates the annual resident and fellow report for Corporate Medical Affairs.
  • Collects appropriate facility-specific forms required for onboarding.
  • Supplies affiliate hospitals with information needed for SHC providers to be credentialed and privileged at the affiliate.
  • Facilitates and executes the onboarding and offboarding of all providers, including coordinating PDCF processes, collecting required documents, coordinating computer training, local drug testing, criminal background checks, and orientation, and provides necessary information to the CVO.
  • Collaborates with the pharmacy director to enroll all providers in EPCS (electronic prescription of controlled substances).
  • Works with the Medical Staff on the development and delineation of clinical privileges and the approval/maintenance of privilege forms every 5 years per the Medical Staff Bylaws.
  • Handles License Procurement Renewals (in coordination with the Telehealth License Coordinator), telehealth license request forms, CME requirements/tracking, and monitoring of expirations.
  • Performs ad hoc job-related duties as assigned.
• Communication and Coordination
  • Maintains open communication and collaboration with the CVO on any pertinent information related to the Medical Staff and advanced practice professionals.
  • Develops, plans, and manages the operational aspects of the Medical Staff committee structures; promotes and enhances good communication and positive working relationships.
  • Provides administrative support to Medical Staff and Advanced Practice Professionals as required.
  • Manages maintenance of curriculum vitae, academic postings, and publications, and submits them to the Chief Medical Officer (CMO) unless otherwise assigned.
  • Ensures coordination and data collection for HDQ Provider Enrollment to ensure timely enrollments unless otherwise assigned.
  • Manages and maintains Medical Staff travel requirements and submits annual summary reports to the CMO per the Medical Staff Bylaws unless otherwise assigned.
  • Generates queries and reports from the credentialing and privileging database as requested.
  • Works with COS on call schedules, timekeeping, contracts, budgets, expenses, and communicates with on- and off-site providers.
• Quality
  • Collaborates with COS, Performance Improvement Director, and other leaders to develop OPPE indicators, data sources, and data submission responsibilities and processes.
  • Coordinates, tracks, and monitors the Medical Staff and Advanced Practice Professional Staff for OPPE (Ongoing Professional Practice Evaluation) and FPPE (Focused Professional Practice Evaluation) processes to ensure compliance with regulatory standards and Medical Staff policies.
  • Coordinates review of OPPE data by the Chief of Staff and/or President of the Medical Staff every six months to comply with SHC standards and supplies this information to CVO for processing reappointments.
  • Collects data on low or no volume providers from outside sources to meet regulatory requirements.
  • Ensures required certification, training to support privileges/prerogatives, and annual education is completed and maintained (e.g., SHINE modules, PALS, BLS).
• Compliance
  • Maintains legacy paper credential files according to the retention schedule and creates and maintains a provider log for all paper files.
  • Interprets federal, state, local, and government/insurance agency regulations and guidelines, as well as local Medical Staff Bylaws, SHC Hospital Regulations and Procedural Rules, policies, and procedures; advises providers, management, and administrators on compliance issues as appropriate.
  • Participates in the ongoing assessment of governing documents to ensure continuous compliance and addresses identified gaps with providers and COS as needed.
  • Facilitates due process that complies with the Medical Staff Bylaws, as well as applicable legal, state, and regulatory requirements.
  • Participates in Joint Commission Surveys regarding privileging, Medical Staff functions, quality, policies and procedures, Medical Staff Bylaws, and Hospital Regulations and Procedural Rules.
  • Ensures Medical Staff Bylaws are reviewed and updated as needed, as well as timely compliance with HDQ-Amendment Team recommendations.
  • Creates, reviews, and updates medical staff policies and facilitates the approval process and upload into Compliance 360 software unless otherwise assigned.
  • Facilitates obtaining maintenance of certifications and board certification waivers according to the Hospital Regulations and Medical Staff Bylaws.
  • Assists the Chief of Staff and/or the President of the Medical Staff in the annual election of Medical Staff officers unless otherwise assigned.
• Meetings
  • Schedules, coordinates, prepares agendas, and takes minutes for Medical Staff committees as outlined in the Medical Staff Bylaws.
  • Prepares BOG summary reports of credentialing/privileging recommendations and ensures the flow of information and action items for Medical Staff committees outlined in the Medical Staff Bylaws, and communicates credentialing decisions to the CVO.

Requirements

• High school diploma or equivalent (GED) required.
• Ability to communicate effectively, both orally and in writing, with all levels of the organization required.
• Ability to use independent judgment and to manage and impart confidential information required.
• Excellent interpersonal skills required.
• Excellent verbal/written skills, including accurate and concise minute and report presentation skills required.

Preferred Qualifications

• Associate Degree in Medical Staff Services preferred, or a combination of education and management experience deemed equivalent.
• Three years in Medical Staff Services and/or five years in hospital experience preferred.
• Knowledge of Medical Staff affairs operational processes preferred.
• Knowledge of related accreditation and certification requirements preferred.
• Knowledge of federal and state regulations preferred.
• Working knowledge of clinical and/or hospital operations and procedures preferred.
• Working knowledge of Medical Staff policies, regulations, and bylaws and the legal environment within which they operate preferred.
• Highly organized, detail-oriented individual able to handle a multitude of tasks preferred.
• Experience with one or more Joint Commission surveys, including preparation of Medical Staff for interviews and attendance/participation in previous surveys, is a plus.
• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) preferred.

Pay

Compensation is determined based on years of relevant experience and departmental equity.