Position provides day to day coordination of the medical staff functions, which includes preparing for meetings, coordinating the credentialing and privileging process, participating in quality assessment and improvement activities. Provides support to leadership and information to the Credentials Committee, Medical Executive Committee and the Governing Board regarding credentialing/privileging and medical staff corrective actions.
Coordinates and facilitates medical staff and advanced practice professional credentialing and privileging at the time of initial appointment and biennial reappointment. Ensures privilege request forms are up-to-date and reflective of the scope of practice. Maintains the accuracy of the credentialing data base, and utilizes the data base to track and manage information.
Serves as a liaison between the medical staff, administration, ancillary departments and patients. Documents and refers complaints and/or concerns about medical staff members to the proper individuals for evaluation and resolution of complaints or concerns.
Ensures practices and procedures are in accordance with Joint Commission, Centers for Medicare and Medicaid Services (CMS), State of Wisconsin and other regulatory agency requirements, hospital and system-wide policies. Responsible for the Joint Commission survey and survey preparation related to the Medical Staff Chapter. Provides ongoing support to leaders to ensure compliance with Bylaws, policies and regulatory requirements.
Coordinates and manages the onboarding and orientation of newly appointed practitioners to the Medical Staff and Advanced Practice Professional staff, including development and implementation of the orientation materials and schedules. Ensures accurate entry of privileges, arranges authorization process to allow practitioners electronic medical record access, makes all appropriate entries into the credentialing software to activate the practitioner and ensure practitioner inclusion in rosters, directories, and reports.
Responsible for creating monthly reports for the Governing Board on credentialing and privileging recommendations of the Medical Executive Committee, as well as on proposed Medical Staff Bylaws, Policy and Rule revisions.
Collaborates with the quality management department to develop and distribute OPPE reports. Ensures Department Chiefs and Section Chairs receive OPPE data for the practitioners in their Department or Section and have access to OPPE data at the time of reappointment.
Coordinates the FPPE process according to regulatory requirements. Researches and recommends FPPE criteria for department chair approval and ensures that all new applicants undergo FPPE within established timeframes, following up with proctors and/or reviewers as necessary.
Responsible for supporting assigned medical staff department and committee meetings, ensuring accurate and timely minutes are recorded and filed, and all necessary meeting-related follow-up activities are completed.