Medical Staff Services Head

Medical Staff Services Head

Provides administrative management, leadership, and direction of the Medical Staff Services (MSS) office and MSS initiatives to ensure ongoing accreditation by The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), National Commission for Quality Assurance (NCQA), URAC, state and federal regulators, and all managed care payers. Manages and coordinates all appointment/reappointment, and credentialing and privileging processes within Michigan Medicine, ensuring strict compliance with applicable rules and regulations of the accrediting bodies and with Michigan Medicine policies. Works closely and effectively with the Administrative Director for Medical Staff Services, the Chief Medical Officer, Chief of Staff, Chair of the Credentialing and Privileging Committee, hospital leadership, clinical departments, Medical School, and the Office of General Counsel in order to provide required services. Ability to analyze, compare, and evaluate various courses of action, and have the authority to make independent decisions on matters of significance, free from immediate direction, within the scope of their responsibilities. Primary activities and decision making authority are predominantly performed independently affecting business operations to a substantial degree. Continually reviews processes to assess overall compliance with accrediting bodies; develops and implements policies, procedures and data collection to facilitate this ongoing effort. Works closely with clinical departments, and physician faculty to identify and implement supportive or corrective processes to manage accreditation requirements.

Responsibilities

Leadership

• Provide strategic leadership to MSS
• Oversight for performance improvement initiatives and activities
• Provide input on budget/financial objectives
• Approval of expenditures
• Long-term maintenance and support for affiliate credentialing, health plan audits, and vendor contracts
• Credentialing and privileging initiatives
• New privilege/new technology requests
• Represent MSS at routine and ad hoc committees

Operations

• Manage day-to-day operations of permanent staff that include credentialing specialists, database administrator, project manager, and administrative assistant
• Makes decisions on hiring, promotions, disciplinary action
• Manage and monitor staff workload
• Monitors staff performance
• Developing and managing staff performance improvement plans
• Set team goals
• Procedure manual development and ongoing maintenance
• Staff performance metric development and reporting
• Timekeeping
• Position request, posting, and hiring processes

Performance and Process Improvement

• Leads and participates in LEAN weekly huddles
• Use Lean in Daily Work methodology for process improvement
• Monitors key metrics that drive performance
• Monitoring performance goals of direct reports
• Maintaining and monitoring all staff metrics at the individual and team level
• Establishes targets and thresholds for performance
• Engages staff in improving performance
• Develops and documents standard work for all important business processes

Policy Management

• Creation, maintenance, and updates of Medical Staff Services policies
• Provides input on relevant Bylaws updates/revisions related to Credentialing and Privileging
• Advises on policy interpretation
• Collaborates with others on development of health system-wide policies
• Medical Staff policy management (coordinating with external departments)

Credentialing and Privileging

• Internal file audit for accuracy and compliance with regulatory requirements
• Leads initiatives to move to a paperless credentialing process
• Staffing Michigan Medicine Credentialing Committee, coordinating agenda setting and managing follow-up items
• Document management for all MSS forms
• Delegated credentialing under affiliate contract for UM practitioners practicing at affiliate sites
• Privileging document development and oversight of ongoing document maintenance
• Manage appropriate escalation of findings during the credentialing process, coordinating with the Chief of Staff, Associate Chief of Staff for Credentialing and Chair of Credentialing and Privileging Committee, Administrative Director of MSS, Department Chair, or Service Chief when appropriate

Regulatory Readiness

• Coordinates delegated payer audits for all contracted health plans
• Participation in TJC, CMS, and state licensing surveys. This requires the ability to travel to the main hospital from MSS office as needed. If working remotely, requires travel to Michigan Medicine for announced and unannounced surveys.
• Works closely with the Office of Clinical Affairs on identified issues
• Managing performance improvement plans/corrective action plans if needed
• Ensures appropriate disciplinary action and sanctions are reported to outside agencies

Affiliations, Acquisitions, and Mergers

• Acts as MSS lead for due diligence review to identify gaps and best practices specific to credentialing and privileging for new healthcare acquisitions, contracts, or affiliations
• Maintains ongoing due diligence with affiliates ensuring alignment with current policies and procedures
• Development and maintenance of delegated credentialing contracts and telemedicine agreements
• Long-term maintenance of affiliate relationships
• Representation on affiliate credentialing committees

Finance, Budget, and Contracting

• Evaluates key financial, budgetary and other metrics related to operations
• Provides information, trends or other conditions that may affect operations or budget planning
• Participates in the development of FTE budgetary expenses, operational expenses and capital budgets in coordination with the Administrative Director and Office of Clinical Affairs
• Manages current vendor contracts for MSS
• MSS lead for delegated facility and payer credentialing contract development and review

Travel

• Approximately 10% travel for offsite meetings and conferences

Required Qualifications

• Bachelor's degree in Business, Public Health, Administration or other related field.
• CPMSM (Certified Professional Medical Staff Management) certification from NAMSS or certified within five years of employment
• Considerable knowledge of CMS, TJC, NCQA, and URAC rules and regulations as they relate to hospital accreditation, credentialing, and privileging
• Ability to commit to and meet deadlines, while not compromising quality
• Must be extremely detail oriented and able to handle multiple projects, prioritizing workload to maximize efficiency
• Outstanding verbal and written communication skills, as well as advanced organizational skills
• Strong record of working effectively with staff in a diverse environment

Desired Qualifications

• Master's degree in Business, Public Health, Administration or other related field, or an equivalent combination of education and experience
• At least 5 years' experience in management with supervisory experience
• Experience managing a Medical Staff Office (MSO), Credentialing and Privileging Office, or Credentials Verification Organization (CVO)
• Trained in LEAN principles for healthcare
• Experience with CACTUS from symplr software
• Knowledge and understanding of the University of Michigan Health System policies and procedures
• Experience in an academic medical center