Mgr- Medical Staff & Cred

Northern Light Mercy Hospital

Department: Medical Staff Administration

Position is located: Mercy Fore River

Work Type: Full Time

Hours Per Week: 40.00

Work Schedule: 7:30 AM to 5:30 PM

Summary:

The Medical Staff Manager plays a key role in the planning, development, management and on-going review of Medical Staff programs as they relate to credentialing/privileging, regulatory compliance and provider relations. The incumbent collaborates with Medical Staff leadership and hospital administration in the establishment of medical staff procedures as they relate to appointments, reappointment, and all other credentialing/privileging related activities. The incumbent is responsible for Medical Staff compliance issues as they relate to State and Federal law, the Joint Commission standards and state hospital licensing regulations. The Medical Staff Manager provides high level administrative support for the Vice President, Senior Physician Executive, Officers, Department/Division Chiefs, and Committee Chairs, and fosters an excellent relationship with the Medical Staff as a whole. The incumbent is a resource for Medical Staff governing documents including bylaws, rules, regulations, and related policies and protocols. Manages the Medical Staff budget, investments, revenues and disbursements. Interacts with external customers such as regional and corporate colleagues with credentialing responsibilities, licensing officials, and regulators. Develops and manages programs, services, and activities related to the human subject research activities at Mercy Health System of Maine. Assures compliance with all governmental and institutional guidelines and policies to protect the health and safety of human subjects. Serves as the institution's Human Protections Administrator and registers as such with the Office of Human Research Protections (OHRP) and the Food and Drug Administration (FDA). The incumbent performs duties in accordance with performance standards. The incumbent may have access to highly confidential patient, employee, and Mercy proprietary information, and must handle and protect the information in accordance with hospital and system policies, HIPAA requirements, and the highest level of ethical standards. The incumbent is responsible for reporting all security events, potential events, and other security risks to the organization. The incumbent is accountable for employee safety and will attend safety and loss-control training, engage in injury prevention, perform accident and injury investigations including conducting root cause analysis, and assist in returning employees to regular duty. The incumbent is responsible for participating in and completing all patient safety initiatives appropriate to the position and conducts all job responsibilities according to the mission and values of the organization.

Responsibilities:

• Corporate Compliance.
• Communicates and enforces the system-wide Corporate Compliance Program for Northern Light Mercy Hospital.
• Reports any potential or real ethical, legal or regulatory violations to the Corporate Compliance Officer.
• Encourages staff to report Corporate Compliance issues either directly or through the Mercy Compliance Line (may be anonymous).
• Facilitates investigations into alleged violations, and the development and implementation of disciplinary and/or corrective action as indicated.
• Continually assesses the department for compliance with all federal, state, local and other regulatory (the Joint Commission, OSHA, CMS etc.) requirements.
• Completes annual staff training, ensuring staff understanding of participation in the above.
• Responsible for the credentialing, privileging and reappointment of the Medical Staff members and Health Professional Affiliate staff.
• Is responsible for ensuring that primary credentialing, privileging, reappointment, and all other credentialing/privileging activities are performed within federal and Maine state law, the Joint Commission standards and state of Maine hospital licensing regulations.
• Researches and creates new privileging criteria and related credentialing protocols.
• Oversees the management of all provider data for members of the Medical Staff, Health Professional Affiliate Staff as well as medical students and residents for use as deemed appropriate by administration and clinical personnel of the hospital.
• Designs, prepares and distributes as appropriate both routine and special reports through use of the department's Medical Staff software and the hospital-wide information system.
• Plans, organizes and directs a comprehensive specialized program for Medical Staff Services to assure continued accreditation by the Joint Commission, compliance with CMS conditions of participation and any other applicable regulatory requirements, statues and laws.
• Supervises and directs volunteers, staff, and independent contractors in the direct performance of the work of the medical staff.
• Provides leadership for compliance with Joint Commission, CMS, state, federal and other regulatory standards relative to Medical Staff including Medical Staff Bylaws, rules and regulations.
• Plans, develops and administers policies relating to all aspects of the organized Medical Staff.
• Ensures that policies, procedures and reporting are in compliance with all regulatory guidelines.
• Conducts regular review of Medical Staff governing documents to ensure regulatory compliance.
• Makes recommendations to the Medical Staff for appropriate change and facilitates approval of amendments.
• Provides information to members of the Medical Staff and Health Professional Affiliate Staff regarding new or changed regulations, policies, procedures and/or programs.
• Oversees coordination of all functions of the Medical Staff committees and department structure.
• Collaborates with Medical Staff leaders to plan, organize and maintain their responsibilities.
• Contributes to the ongoing functions of the Medical Staff quality improvement plan through participation in Medical Staff committee and department/division meetings.
• Provides guidance to committee and departmental chairpersons as needed.
• Researches and prepares confidential reports for the Quality Professional Affairs Committee, Medical Executive Committee, Credentials Committee, Department of Medical Services, Department of Surgical Services and other medical staff committees and divisions.
• Tracks medical staff issues through committee and departmental reporting structure providing reports on status and outcomes.
• Provides professional and technical assistance to members of the medical staff with special attention to medical staff leadership.
• Develops and maintains an excellent relationship with the Medical Staff and Health Professional Affiliate Staff and promotes and enhances positive provider relations with the organization.
• Responds promptly to requests for service and solicits provider feedback to improve service.
• Provides expertise to the VP Senior Physician Executive in managing challenging provider situations.
• With Medical Staff Specialist, organizes annually a Medical Staff Banquet for members of the Medical Staff, Health Professional Affiliate Staff, and Board of Trustees.
• Fosters a culture of Medical Staff recognition and collegiality through a series of special events.
• Identifies, analyzes and responds to provider concerns regarding Medical Staff programs and implementing strategies to enhance service.
• Manages projects as determined by the Director of Quality and the VPMA.
• Manages the finances of the Medical Staff.
• Activities within this function include but are not limited to; oversee collection of revenues, disbursement of funds and investments, advises Medical Staff regarding fund management and adjustments, provide financial reports to Medical Executive Committee at least annually.
• Manages the finances of the Medical Staff on behalf of the Medical Staff Treasurer.
• Manages the finances of the Medical Staff. Activities within this function include but are not limited to; oversee collection of revenues, disbursement of funds, investments, advises Medical Staff regarding fund management and adjustments, provide financial reports to Medical Executive Committee at least annually.
• Compliance with federal and state regulations and requirements.
• Registers as the institution's Human Protections Administrator with the Office of Human Research Protections (OHRP) and the Food and Drug Administration (FDA).
• Maintains updated FDA and OHRP numbers for Mercy Health System of Maine.
• Develops and maintains a system that assures that IRB activities are compliant with federal regulations and state and local laws relative to the conduct of human subject research.
• Plays a key role in routine FDA audits for regulatory and legal compliance.
• Maintains IRB and FWA registrations with the Department of Health and Human Services (DHHS).
• Updates registrations within 90 days after changes to IRB occur.
• Administrative coordinator for IRB.
• Provides administrative direction for the review of human research protocols (initial, expedited and annual reviews); this includes the IRB submissions which must be accurate, complete, and comply with all applicable Federal regulations, State and local laws and assures that these protocols meet IRB guidelines prior to IRB member review.
• Coordinates the process for IRB exemptions and eligibility for expedited reviews by working in collaboration with the IRB Chairperson assuring in all cases that federal guidelines are followed.
• Works closely with institution's clinical research staff and the Chairperson of the IRB to ensure federal regulations and institutional policies and procedures are followed.
• Develops, coordinates, and manages all IRB operational processes to ensure compliance with federal and state guidelines. Develops and maintains IRB operating policies and procedures.
• Maintains an accurate and current database of all clinical research studies and protocol activities as required by federal and regulatory requirements, including annual review, amendments, and closed studies.
• Manages and tracks records and documents for protocols utilizing a Central IRB.
• Acts as the institution's Human Protections Officer and is responsible for the tracking and reporting of adverse events reports submitted to the IRB.
• Develops and maintains a system for invoicing and collection of fees related to IRB activities.
• Acts as the institution's liaison with outside organizations including the OHRP, FDA, institutional officials, and researchers.
• Provides orientation to all IRB member appointees and ensures completion of required training.
• Provides educational opportunities for IRB members and Principal Investigators.
• Is a member of EMHS&'s Research Compliance Workgroup.
• Monitors federal, state and local laws, regulations and guidelines governing human subject research.
• Studies current literature, attends educational and professional conferences/seminars as required to stay current and compliant in areas related to human subject research compliance.
• IRB meeting coordination.
• Is the designated staff person for the IRB committee meetings.
• Coordinates the meeting preparation, invitations, agenda, and minutes, and clearly communicates such to all IRB members.
• Completes the preparation and circulation of the yearly IRB meeting schedule.
• Documents medical and ethical issues that arise from committee discussions and ensures accurate documentation of final committee determinations.
• Works in collaboration with the IRB Chairperson and composes outcome letters regarding the IRB decisions, concerns and need for follow-up activity as it pertains to protocols submitted for review.
• Distributes outcome letters in a timely fashion to trial sponsor, principle investigator, and clinical research sites.
• Communicates with IRB members and outside investigators on IRB protocol requirements and regulations and changes in standard operating policies and procedures.
• Ensures IRB members have no conflicts of interest.
• Performs additional duties as required or assigned.

Other Information:

Competencies and Skills

• Behaves with Integrity and Builds Trust: Acts consistently in line with the core values, commitments and rules of conduct. Leads by example and tells the truth. Does what they say they will, when and how they say they will, or communicates an alternate plan.
• Cultivates Respect: Treats others fairly, embraces and values differences, and contributes to a culture of diversity, inclusion, empowerment and cooperation.
• Fosters Accountability: Creates and participates in a work environment where people hold themselves and others accountable for processes, results and behaviors. Takes appropriate ownership not only of successes but also mistakes and works to correct them in a timely manner. Demonstrates understanding that we all work as a team and the quality and timeliness of work impacts everyone involved.
• Practices Compassion: Exhibits genuine care for people and is available and ready to help; displays a deep awareness of and strong willingness to relieve the suffering of others.

Education

• Required Bachelor's Degree

Working Conditions

• Potential exposure to abusive and/or aggressive people.
• Work with computers, typing, reading or writing.
• Lifting, moving and loading 20 to 30 pounds.
• Prolonged periods of sitting.
• Prolonged periods of standing.
• Prolonged periods of walking.