Location: BBC Bronson Battle Creek, BMH Bronson Methodist Hospital

Title: System Director of Medical Staff Services

Job Summary: Reporting to the Vice President/Medical Affairs, the System Director of Medical Staff Services manages and enhances the functions of the organized medical staff. This includes overseeing the overall credentialing process, ensuring compliance with accrediting bodies and regulatory requirements, and supporting medical staff leadership in governance and communications.

Job Description:

Management of Medical Staff Services:

Manages the overall operations of the Medical Staff Department, providing direct supervision to Medical Staff Coordinators, Medical Staff Supervisors, Onboarding Specialists, Project Coordinators, and Administrative Assistants.
Completes evaluations for team members and manages time and attendance/payroll functions.
Responsible for fiscal accountability, including overseeing the department budget and maintaining accurate records of application fees and reappointment processes.

Credentialing Process:

Oversee the thoroughness of the credentialing process, including the review and reappointment of new physician applicants and those currently on staff.
Ensure all verifications (education, experience, malpractice history, competency) are completed on time and in accordance with Joint Commission and CMS standards.
Address red flags or incomplete documentation during the credentialing process and escalate concerns to senior leadership as needed.
Submit recommendations from the Credentials Committee to the Medical Executive Committee for final approval by the Board of Directors.

Privileging Process:

Ensuring that all practitioners applying to Bronson meet the requirements set forth in the Credentials Policies and privilege forms.
Ensuring that all privilege forms and documents are reviewed every two years and kept up-to-date with national standards.
Ensuring that all practitioners that go through reappointment are meeting their required number of procedures and that they remain competent.
Ensuring that all practitioners go through Focused Professional Practice Evaluation (FPPE) within the standard timeframe as outlined in the FPPE Policy.

Compliance and Legal Standards:

Work closely with VPMA, Medical Staff Elected Officials, and the Medical Staff Leadership to ensure that the Medical Staff Bylaws, Rules, and Regulations are reviewed and revised regularly.
Maintain compliance with Joint Commission and CMS standards to ensure that the organization is survey-ready at all times.
Oversee the department’s adherence to safety and compliance regulations.

Leadership and Supervision:

Provide direct assistance to the Chief of Staff, Vice President of Medical Affairs, and all elected officers of the medical staff in confidential matters.
Coordinate and attend special meetings, ensuring accurate record-keeping and distribution of meeting materials.
Mentor and guide the medical staff team, focusing on developing leadership potential within the team.

Drug Screening & Compliance:

Enforce established protocols for drug screening across all medical staff.
Prevent the escalation of problematic hires that could lead to patient harm or legal liabilities.

Fair Hearings and Legal Expertise:

Lead the department in handling complex medical staff legal issues.
Utilize a strong understanding of legal frameworks to mitigate risks and ensure compliance.

Election Management:

Manage the biannual election process for the medical staff.

Employee Management:

Oversee the performance and productivity of the team responsible for processing applications and reappointments.
Address employee issues, taking action when necessary.

Additional Duties:

Maintain accurate and updated lists of medical staff.
Coordinate the creation and distribution of the monthly Medical Staff Newsletter.
Responsible for maintaining the Physicians and Advanced Practice Professional webpage.
Assist with OBRA and Run Loss Reports.

Qualifications:

Education:

Bachelor required.
Master’s Degree preferred.

Experience:

5-8 years of experience required in medical staff services, credentialing, and legal compliance.
Experience with high-stakes hearings, privileging issues, and legal disputes is essential.

Skills:

Excellent communication and customer relations skills.
Proficiency in clerical skills, grammar, spelling, and basic math.
Strong computer and interpersonal skills.
Ability to manage multiple priorities and work independently.

Work Environment: The role requires coping with the anger, fear, or hostility of others in a calm manner while handling confrontation and problem resolution.

Shift: First Shift

Time Type: Full time

Scheduled Weekly Hours: 40

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