Strength Through Diversity
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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.
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.
Strength Through Diversity
The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.
We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care.
Explore more about this opportunity and how you can help us write a new chapter in our story!
Who We Are
Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation.