Purpose
This position is an integral part of the Medical Staff Services Team and is accountable for meticulously following regulatory standards, federal and local statutes, credentialing policies and procedures, and maintenance of an accurate physician data base. This role also serves as a guide for practitioners in navigating organizational requirements; serves as a resource for internal and external stakeholders; and participates in the development implementation of process improvement initiatives. Uses independent judgement and problem-solving skills demonstrating discretion and sound judgement in the decision-making process. Functions independently, with little or no day-to-day supervision.
Essential Functions
Medical Staff Liaison:
Serves as primary point of contact for assigned specialties to ensure provider and stakeholder satisfaction across multiple hospitals, ensuring consistency and quality in service delivery.Ensures coordination and alignment of medical staff services processes and procedures across the region, promoting a cohesive and collaborative environment.Assists providers and stakeholders in navigating organizational requirements, addressing concerns, and facilitating effective communication to promptly resolve issues. Maintains a customer-focused attitude, good rapport, and cooperative relationships. Approaches conflict in a constructive manner. Helps to identify problems, offer solutions, and participate in their resolution.Develops strong relationships with medical staff and administrators across THMI, understanding needs, preferences, and goals to ensure satisfaction and trust. Works closely with department leaders to ensure needs are met and expectations are aligned.Interprets and conveys medical staff requirements clearly to internal teams and external stakeholders with updates and information as needed.Provides training and support to medical staff and medical staff leaders within assigned specialty areas on credentialing and privileging processes, regulatory requirements, and hospital policies.Orients new medical staff leaders to MSS processes and applications.Serve as a liaison between medical staff, hospital administration, and external regulatory bodies.Onboarding and Ongoing Support:
Manages all elements of assigned medical staff specialty areas, including the onboarding of new applicants to the medical staff, analyzing information to determine eligibility and demonstrated competence, required follow-up to ensure rapid completion of applications to meet target dates for completion while exercising sound discretion and professional judgement in decision making.Monitors CPI progress and alignment of medical staff process to ensure timely progress and compliance with target dates of completion.Manages the reappointment, request for change and resignation processes.Ensures compliance with FPPE requirements and timelines for completion.Meets processing time thresholds consistently and with minimal error.Regulatory Compliance and Accreditation:
Ensures compliance with all relevant regulatory and accreditation standards, including Joint Commission, CMS, and state-specific requirements.Manages the credentialing and privileging processes for medical staff, ensuring all necessary qualifications and standards for compliance with regulatory, statutory and hospital requirements are met.Assists in the direction and maintenance of a comprehensive and specialized credentialing program to assure continued accreditation by The Joint Commission (TJC) and other regulatory organizations, including assistance with accreditation surveys.Serves as a resource to interpret, explain, and follow all regulatory guidelines, including medical staff bylaws, rules and regulations and polices. Maintains a working knowledge of applicable Federal, State and local laws/regulation, and organizational policies and procedures in order to ensure adherence.Monitors delineation of privilege forms to ensure they reflect current standards in training, competency requirements, and standard of care, as well as the identification of necessary changes and opportunities for alignment.Assists with the development and maintenance of privilege request forms, policies and procedures.Quality Assurance and Improvement:
Performs ongoing Data Analysis, auditing and maintenance of the Medical Staff database and supporting documentation to ensure data and information integrity to support internal practices and the data integrity of the patient-facing marketing website.Participates in quality improvement initiatives and supports the implementation of best practices in Medical Staff Services across the THMI region.Assists in Medical Staff Services workflow management, identifying outdated processes and wasted resources, tracks errors and complaints to assist with process improvement activities.Other
Collaborates in support of the Credentials, Medical Executive, and other Medical Staff Committees.Assists in the training and orientation of new team members.Maintains the confidentiality of information acquired pertaining to patient, physicians, colleagues, and external entities. Discusses patient and hospital information only among appropriate personnel in appropriately private places.Uses tact, discretion, and objectivity in dealing with confidential and highly emotional situations.Participates in professional development programs and professional organizations to grow in understanding of the various regulations and legislation of the health care to develop extensive knowledge of Joint Commission, CMS, and Michigan regulations and standards as they relate to Medical Staff functions.Performs other duties as assigned.Maintains a working knowledge of applicable Federal, state & local laws/regulations, Trinity Health Integrity & Compliance Program & Code of conduct, as well as other policies & procedures in order to ensure adherence in a manner that reflects honest, ethical & professional behavior.
Minimum Qualifications
Education: Associate’s degree in healthcare administration, business administration or similar degree OR equivalent.
Experience: A minimum of 2 years of healthcare environment or healthcare administrative/office experience and general knowledge of the health care industry including hospital settings and physician practices with a working knowledge of federal, state and TJC accreditation standards and general medical terminology.
Certification/Licensure: None required.
Required:
Proficiency with MS Outlook, Word, and Excel.Excellent interpersonal, verbal, and written communication skills necessary to facilitate communication, collaboration, and interaction, including the ability to correspond effectively in writing, as well as verbally convey information clearly, and listen actively, with all levels of hospital personnel, medical staff and external agencies and organizations regarding MSS functions. Exceptional organizational skills, attention to detail, thoroughness, and critical thinking skills. Analytical ability to identify opportunities for improvement and problem resolution within assigned specialty areas. Ability to manage changing priorities and work with frequent interruptions, exercise independent thinking and judgment, and to work without direct, day-to-day supervision. Strong customer-service ability and desire to provide quality service to others. Ability to work autonomously and within a team, and to function in matrixed environment. Ability to challenge established ways of doing things in a constructive manner. Must possess the ability to comply with Trinity Health policies and procedures.Additional Qualifications (preferred)
Medical staff services, hospital credentialing and privileging, and peer review experience.Certified Professional Medical Staff Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS). Proficiency with credentialing software.In-depth knowledge of regulatory standards, credentialing processes, and healthcare administration.Our Commitment
Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.