Director- Medical Staff Administration

JOB SUMMARY : Directs, coordinates, plans, and oversees the development and administration of the operation of the Medical Staff Office including all credentialing processes; Medical Staff committee and department meetings; development and presentation of all continuing medical education scientific and medical seminars; Institutional Review Board; and Medical Research Studies. Ensures compliance with regulatory agencies, Texas Medical Association and JCAHO standards, St. Joseph Medical Centers' Bylaws, General Rules of the Medical Staff, and all policies, procedures, and guidelines.

REPORTING RELATIONSHIPS : Medical Staff Coordinator, Credentialing Specialist, CME / Medical Research Coordinator

Shift : Day shift

PRINCIPAL DUTIES AND RESPONSIBILITIES :

1. Consistently supports the hospital's Spirit of Serving Standards, in line with the Mission, Vision and values of St. Joseph Medical Center.

2. Follows the St. Joseph Medical Centers' Guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)

3. Promotes a culture of safety for patients and Associates through proper identification, proper reporting, documentation and prevention of medical errors in a non-punitive environment.

4. Effectively train, supervise, and motivate personnel in the Department.

5. Develop and implement policies and procedures to maintain compliance with all regulatory agency requirements.

6. Prepares and reconciles Medical Staff Services and CME / Medical Research budget and oversees financial operations of the Department.

7. Oversees support of medical staff meetings and ensures compliance with Robert's Rules, medical staff bylaws, and regulatory standards.

8. Assures compliance to JCAHO standards by the medical staff with regard to credentialing physicians and HPS.

9. Serves as a resource to the medical staff in medical staff issues, including Bylaws, rules and regulations.

10. Oversees implementation of the appointment and reappointment process.

11. Assures compliance to JCAHO standards by the medical staff with regard to its Bylaws and rules and regulations.

12. Oversees and supports medical staff meetings including compiling agendas, minute taking, and follow-up.

13. Coordinates and participates in special events sponsored by Medical Staff Services, i.e., Doctor's Day, Annual Medical Staff Meeting, and additional events assigned by Administration.

14. Assures the three essentials for the CME program are met in order to maintain accreditation for the Hospital by the Texas Medical Association by preparing and maintaining detailed documentation.

15. Provides oversight of the development and implementation of education / planning seminars.

16. Oversees the maintenance of the seminar budget (i.e. balance and entry of deposits, check requests, and supplies information).

17. Initiates and participates in Performance Improvement activities as it relates to the medical staff and quality issues.

18. Manages and provides overall support for medical staff leaders.

19. Oversees the coordination of the Institutional Review Board to ensure compliance with regulatory agencies.

20. Supportive of the compliance program set forth by SJMC and demonstrated by :

a. Upholds the Code of Ethics and Corporate Compliance.

b. Adheres to dealing appropriately and fairly with employee misconduct.

c. Enforces all compliance policies as they pertain to his / her area.

d. Provides and assures timely compliance education as requested by the Compliance Officer and / or through corporate initiatives.

21. Sets an example to all staff in their daily activities.

22. Supports, reviews, and understands JCAHO's compliance activities and expectations. Ensures departmental compliance with JCAHO standards.

MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED :

Work Experience : Level of knowledge typically gained through three to five years medical staff coordinator experience in order to have self-starter skills and require minimal supervision. Experience gained through health care and specific related fields will contribute to effective management and supervisory requirements.

License / Registration / Certification : Certified Professional Medical Staff Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS).

Education & Training : Minimum 4-year degree or 2 years of college or equivalent experience with minimum 5 years management and / or supervisory experience in healthcare or related health care environment. Familiarity regarding functions, services, and compliance requirements and hospital medical staff functions.

Skills : Ability to be a self-starter, manage time appropriately, be detail minded and require minimal supervision. Communication skills essential to effectively communicate with physicians, hospital administration and personnel, associates and agencies, and other individuals in the daily operations in a Medical Staff Services Office.

Houston's oldest hospital is GROWING!

Welcome to St. Joseph Medical Center (SJMC), Houston's first and only downtown hospital delivering world-class care for the last 137 years and looking forward to the next century of exceptional care to Houstonians when they need us most.

Whether it's for a scheduled surgery, the birth of a baby, an unexpected emergency, or an outpatient visit, we have staff available around the clock to provide you access to immediate, quality health care. SJMC has been providing health care services to Greater Houston residents for over 130 years, which should give you great comfort in knowing that we have a great tradition of caring for our community. We strive to meet our patients' expectations and encourage our patients to provide us with feedback on how we can help them have the best experience possible while they're in our care.

Over the last years we have expanded our services to include the Advanced Wound Care Center, Comprehensive Cardiac and Vascular Services, the Women's Center, the St. Joseph Maternal Fetal Medicine Center, and a Weight Loss Surgery Program, just to name a few. As you work with our physicians, nurses, case managers, educators, and other staff, you will be guided through your health care journey, from diagnosis to treatment, with compassion every step of the way.

Diversity, equity, inclusion, and belonging are at the foundation of the care St Joseph Medical Center provides to our community we are privileged to support in all of our employment practices. We do not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or expression or any other non-job-related characteristic.