JOB SUMMARY:
The manager, Medical Staff Quality and Peer Review is the leader responsible for the administrative and monitoring functions related to all efforts around Medical Staff quality. Develops and implements high-level strategies and provides overall system wide management of operations and resources for the Medical Affairs Department. The manager, along with the CMO, is responsible for the development, communication and implementation of a strategic plan to improve the quality and efficiency of Medical Staff quality workflows. Specifically, via the Medical Quality Improvement Committee (MQIC) and Ongoing Professional Performance Evaluations (OPPE). Accountable for the operations of the department in a manner that ensures patient safety, meets or exceeds national quality standards, and is responsive to the needs of staff, patients, and the Medical Staff. Manages, directly and indirectly, the Associates involved in the daily operations of the department. Other responsibilities include financial management, human resource management and management of the revenue cycle for the department in accordance with corporate policies and procedures, regulatory guidelines, and statutes. Models appropriate behavior as exemplified in the EHS Mission, Vision and Values.

Education:
Required:
Bachelor's degree is required.

Preferred:
Master's degree in health/hospital administration, business administration, or advanced certification in credentialing

Experience:
Required:
Comprehensive knowledge of business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the health care industry, particularly related to credentialing and medical staff management.
At least 5 years of progressive experience in managing functions and departments in a clinical or clinical education environment with a knowledge of work flows and systems.
Knowledge of business office operations
Knowledge of process analysis and design
Knowledge of applicable regulatory requirements and their application to credentialing and medical staff quality processes
Proven skills in interpersonal relationships, planning, organizing, and follow-up, budget preparation and monitoring, and management and leadership
Demonstrated ability to set and manage priorities, be a team member and educate others, relate to all levels of the organization, comprehend complex and technical subjects, create and motivate behavior changes, translate financial and technical language to lay audiences, and plan, implement, and monitor processes in a complex health care environment.

Preferred:
At least 3 years of direct management responsibility
Specific experience with Credentialing and Medical Staff management is preferred

Position Requirement(s): License/Certification/Registration
Preferred: medical background (RN, BSN, RT, etc.)

Department Position Summary:
Provides strong leadership and direction in establishing a Medical Affairs Department that meets or exceeds national quality standards. Ensures compliance with hospital, DNV, and other regulatory authorities.
In collaboration with system leadership, will assist in facilitation and coordination of system wide initiatives involving Medical Staff.
Partners with physicians, quality associates, Medical Executive Committee members, and medical affairs staff to create a clear vision for the Department.
Develops a strategic plan that clarifies steps for implementing the vision, reflects an understanding of the anticipated and current needs of the Department and the health system.
Leads and facilitates the effort to integrate all aspects of the Peer Review process
Plans, organizes, develops, and implements operations to meet the needs of our clinicians and the organization at large
Supports, when needed, the members and operations of the Officer's Council including scheduling, management of professionalism reporting mechanisms and responses, and keeping of minutes
In partnership with the CMO, identifies opportunities to expand services offered by Medical Affairs
Prepares and administers an annual expense budget, capital request budget, and human resource utilization plan for services within the Quality/Peer Review section.
Lead business plan development process for new programs and services.
Promotes and builds strong professional and collegial relationships with Medical Staff, ancillary departments, and other internal and external partners.
Provides support on administrative (contractual, legal, financial) matters for the Department.
Develops an office organizational structure that facilitates service line planning and communication.
Maintains regular contact with the CMO, Credentialing Associates, administration, management, staff, and Medical Staff, as well as departments that include Marketing, Nursing, Quality Improvement, senior administration, onboarding, HR, and Finance.
Maintains regular contact with the Dean of the University of Tennessee College of Medicine - Chattanooga, physician practice groups, EHS, various professional organizations, regulatory agencies, other hospitals, and national colleagues.