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Director/Medical Staff Svcs-Credentlal Job

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Date: Sep 23, 2021

Location: Memphis, TN, US

Company: Methodist Le Bonheur Healthcare


Responsible for planning, implementing, directing, and controlling activities, operations, and programs at Methodist Healthcare, including Medical Staff Services, Credentialing, and Cactus initiatives.  Serves in the Medico-legal role for MLH.  Models appropriate behavior as exemplified in MLH Mission, Vision and Values.


  Education/Formal Training Work Experience Credential/Licensure

Master’s degree in Healthcare or related field.

Minimum of five years progressively responsible experience in Credentialing & Regulatory Compliance. N/A



  • Thorough knowledge of health care administration principles, methods and procedures commensurate with requisite education/training.
  • Ability to understand and prepare complex written materials, such as business plans.
  • Ability to communicate verbally with all levels of associates, management, executives, medical staff, patients and families.
  • Ability to lead and motivate individuals and groups of people toward the accomplishment of work and organizational goals.
  • Skill in negotiating with and between individuals and groups of people, including associates, management and physicians.
  • Ability to plan and schedule tasks and projects and to maintain control of own and others' work flow.
  • Skill in developing and implementing long-range plans and programs.
  • Ability to work without close supervision or professional guidance and to exercise independent judgment.

Key Job Responsibilities

  • Responsible for establishing, contributing to and maintaining continuity in the planning, development and implementation of standards applicable to the medical staff organization, related to credentialing  including but not limited to: 1) Planning, developing and implementing departmental goals and objectives; 2) Directing measurement activities to ensure that the Medical Staff activities are in compliance with TJC and other quality and regulatory standards; 3) Responsible for development, implementation and monitoring of processes and work flows for credentials.
  • Responsible for the medical administration and medico-legal aspects of the medical staff organization, serves as custodian of medical staff records.
  • Facilitation of the committee structure, including General Medical Staff meetings, Credentials Committee, Bylaws Committee.  Facilitates the information flow between the departments, medical staff committees, and the MEC, and between the MEC and the board.  
  • Ensures that all credentialing information and outputs are compliant with increasingly complex JOINT requirements, legal trends, and increasing need for precision in privileging.
  • Ensures compliance with the accrediting and regulatory agencies (i.e. TJC, NCQA, CMS, and state in regards to credentialing, maintaining a working knowledge of the applicable statutes and laws.  Facilitates information and file reviews for the accrediting and regulatory agencies.  
  • Collaborates with and guides the medical staff to develop and maintain privileging standards and criteria for delineations of clinical privileges.
  • Serves as witness when needed for legal issues for MLH.
  • Maintains versioning of all bylaws and governing documents and produces appropriate version for legal department and other entities.
  • Monitors state disciplinary and compliance reports for actions taken against credentialed providers.
  • Responsible for update and evolution of CACTUS.  Continual development of Credentialing database as a real-time process tool; ensures all information is formatted and entered accurately. Provides ongoing training and in-service to credentialing specialists and other users.
  • Maintains currency at all times about new developments in regulatory arena (JOINT, CMS, state) with respect to credentialing and privileging. Maintains working knowledge of the medical staff bylaws, rules and regulations, keeping updated and informing medical staff of all changes. 
  • Oversight of all board letters that are sent over CEO signature granting privileges, ensure compliance with regulatory standards. 
  • Ensures that all credentialing is timely and impact lists and other lists are provided to administrators.
  • Leads development of the centralized credentialing office; responsible for integration of changes into CACTUS and interface with the vendor in setting and meeting the requirements. 
  • Develops operational documents and oversee the operations of the CCO.  Oversee all privileging activities.

Physical Requirements

  • The physical activities of this position may include climbing, pushing, standing, hearing, walking, reaching, grasping, kneeling, stooping, and repetitive motion.
  • Must have good balance and coordination.
  • The physical requirements of this position are: light work - exerting up to 25 lbs. of force occasionally and/or up to 10 lbs. of force frequently.
  • The Associate is required to have close visual acuity to perform an activity, such as preparing and analyzing data and figures; transcribing; viewing a computer terminal; or extensive reading.
  • The conditions to which the Associate will be subject in this position: The Associate is not substantially exposed to adverse environmental conditions; job functions are typically performed under conditions such as those found in general office or administrative work.

Nearest Major Market: Memphis

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