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Office of the Hospital President-Req # 2453580
Senior Director-Medical Staff Services
The Senior Director, Medical Staff Services, is the primary administrative liaison between the Medical Staff, Hospital and Health System Administration, and the Governing Body. The incumbent in this role provides leadership and is accountable for ensuring a compliant, streamlined approach to and oversight of: all Medical Staff and Advanced Practice Provider credentialing processes and procedures for the Health System, including delegated credentialing for provider enrollment; maintaining all practitioner competency criteria and clinical privileges; maintaining medical staff governing documents (e.g., bylaws, rules and regulations, and policies and procedures); ensuring a comprehensive approach to ongoing monitoring of practitioner competency evaluations, sanctions, corrective and disciplinary actions; compliance with all relevant state, federal, regulatory and accreditation requirements; and the management of a comprehensive database system that serves as a source of truth for the Health System as it relates to practitioner data.
The Senior Director, Medical Staff Services, supervises the activities of the Directors, Managers, Coordinators, Specialists, and/or other staff within the Department, as applicable.
Role & Responsibilities:
I. CREDENTIALING & PRIVILEGING SYSTEMS A. Plans, organizes and directs a comprehensive credentialing program · Directs all aspects of credentialing for the System, including but not limited to: temporary privileges, appointments, reappointments, status changes and delegated credentialing for health plan enrollment
B. Designs, implements and manages an objective, criteria-based clinical privileging system
Ensures that clinical privileges for all licensed independent practitioners (LIPs) and advanced practice providers (APPs) are criteria-based and reflective of services offered by the appropriate sites.
Remains up to date on best practices in regards to technology-driven solutions to support the functions of a well-developed and streamlined credentialing and privileging process.
Has comprehensive knowledge and experience in evaluating practitioner specific competency for clinical privileges to ensure appropriate privileges are delineated, granted and monitored for ongoing compliance.
C. Interprets, develops and implements policies and procedures to ensure continuous compliance with state/federal statutes and applicable regulatory agencies and accrediting bodies as applicable e.g., CMS, TJC, NCQA, AOA-HFAP, AAAHC, DNV, etc.
Provides ongoing education to team and Medical Staff Leaders as necessary.
Participates on hospital compliance teams and in regulatory and accreditation surveys, as needed.
D. Collaborates with other Health System personnel regarding performance improvement data to help Medical Staff Leaders make informed decisions regarding practitioner competence
Works in conjunction with all relevant hospital departments (clinical and non-clinical) on supporting peer review functions, including but not limited to FPPE, OPPE and performance management.
Collaborates with key staff on managing an ongoing reporting process that is accurate, timely and action driven.
II. CONTROLS, DIRECTS, FACILITATES AND MAINTAINS MEDICAL STAFF GOVERNANCE FUNCTIONS A. Controls and directs the administrative support of governance documents
Ensures that all governance documents, policies, procedures, rules and regulations are compliant, current and accessible to members of the staff.
Protects permanent records by managing a secure record retention process.
III. SUPPORT OF MEDICAL STAFF LEADERSHIP A. Plans and manages an effective Medical Staff meeting management system · Directs meeting activities (agenda development, documentation, follow-up, communication).
Provides guidance on accreditation, regulatory issues, best practices, meeting outcomes and resolution. Consults appropriately with medical staff leaders and legal team on an as needed basis.
B. Plans and manages the administrative support to Medical Staff Leadership allowing them to effectively carry out their duties and responsibilities
Collaborates, develops and implements long and short-term goals.
Manages processes related to investigative, disciplinary and legal proceedings, such as fair hearings and appeals, NPDB reporting, compliance investigations, State Board or other regulatory sanctions and reporting.
Tracks, trends and ensures proper documentation related to all corrective actions.
Serve as a liaison to Medical Staff Leaders to guide them through regulatory or hospital requirements (e.g., ensuring proper policies, procedures and state/federal reporting requirements are met).
IV. MSSD OPERATIONS A. Directs and manages the strategic and daily activities of the department
Responsible for adequate staffing and efficient use of staffing resources.
Responsible for recruiting, training, mentoring, evaluating and disciplining departmental staff.
Establishes standards and analyzes work procedures that promote leading practices and champions innovation.
Controls and manages budget.
Ensures the credentialing database is properly utilized and maintained in order to be a valued source of truth for the System, streamlines processes and feeds accurate data to all downstream systems.
Evaluates and manages all department contracts and vendor relations, and ensuring fiscal responsibility in the use of these services.
V. MEDICAL STAFF AND HOSPITAL COLLABORATION A. Directs the administrative interface with Medical Staff Leaders and Medical Staff organization and Health System Administration, the Governing Body and hospital departments to ensure and enhance effective relationships
Serves as a liaison between Medical Staff and Administrative Leadership.
Effectively collaborates with hospital departments (e.g., human resources, labor relations, occupational health, etc.) to ensure a comprehensive approach to provider recruitment, onboarding and ongoing management of provider data.
A. Supports education, professionalism, practice-based learning and systems based practice
Cultivates positive interpersonal relationships with the members of the Medical Staff, Medical Staff Leaders, Administrative and ancillary staff.
Promotes ongoing education.
Performs environmental surveillance to identify new opportunities.
Serves as a leader on hospital committee’s as needed to represent the needs of the department.
Bachelor’s degree in healthcare administration or equivalent required. Master’s degree preferred.
Minimum of 7 years of medical staff/credentialing leadership experience in a multi-hospital healthcare system is required.
Significant experience in maintaining and managing a credentialing database is required.
CPMSM required; additional certification in CPCS desired.
Must have extensive knowledge in the management of credentialing software; Microsoft Office products (Word, Excel, PowerPoint, Outlook)
Experience in managing medical staff quality & governance (e.g., Medical Staff Bylaws, Policies, Corrective Actions, FPPE, OPPE, Hearing & Appeals, etc.) is strongly preferred.
Experience in an academic medical center is strongly preferred.
Experience overseeing a Centralized Verification Organization is preferred.
Experience overseeing greater than 30 employees is preferred.
Experienced with managed care credentialing is preferred.
Internal Number: 2453580
About Mount Sinai Health System
The Mount Sinai Health System is an integrated health care system providing exceptional medical care to our local and global communities.
Encompassing the Icahn School of Medicine at Mount Sinai and eight hospital campuses in the New York metropolitan area, as well as a large, regional ambulatory footprint, Mount Sinai is internationally acclaimed for its excellence in research, patient care, and education across a range of specialties. The Mount Sinai Health System was created from the combination of the Mount Sinai Medical Center and Continuum Health Partners, which both agreed unanimously to combine the two entities in July 2013.
The Health System is designed to increase efficiencies and economies of scale; improve quality and outcomes; and expand access to advanced primary, specialty, and ambulatory care services throughout a wide clinical network. The Health System includes more than 7,200 physicians, including general practitioners and specialists, and 13 free-standing joint-venture centers. Mount Sinai also features a robust and continually expanding network of multispecialty services, including more than 400 ambulatory practice locations throughout the five boroughs o...f New York City, Westchester, and Long Island. With an extraordinary array of resources for the provision of compassionate, state-of-the-art care, the Mount Sinai Health System is poised to identify and respond to the health-related needs of the diverse populations we serve.