Job Description

Summary:Administers system-wide compliance programs by implementing compliance systems and processes designed to ensure compliance with applicable laws and regulations as well as internal policies and procedures. In conjunction with MLH leadership, develops the system strategies and direction of medical staff focused performance assessment and improvement, and credentialing at MLH. Responsibilities include all aspects of quality, performance improvement and medical staff credentialing including operational support, quality planning and quality monitoring. Utilizes statistical tools, benchmarking resources, performance measurement, quality management and other resources to determine trends, identify opportunities for improvement and lead change of medical staff quality and credentialing within MLH. Leads improvement of clinical processes that depend primarily on LIP. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.
Education/Training & Experience:Required:Bachelor’s degree in Business Administration, Public Health Administration, Health Service Administrative or related field.Minimum of five years of management experience in a healthcare environment.Training and experience in system level quality programs and ability to train others in tools and techniques of Quality Improvement.Experience in a direct role interacting with providers, senior administrative staff and board of trustees.Preferred: Master’s degree in Business Administration, Public Health Administration, Health Service Administrative or related field.Six Sigma certification preferred.
Knowledge/Skills/Abilities:Demonstrated understanding of quality management, statistical analysis, safety and regulatory requirements.Demonstrated knowledge of Informatics, EMR technology, data analysis, and other electronic applications to execute strategies based on system priorities.Strong background in quality, benchmarking, and data analysis, teambuilding and budgeting.Working understanding and knowledge of hospital/healthcare operations and strategy as it relates to quality, accreditation, and quality improvement performance.Familiarity with medical terminology required.Possess effective collaborative skills, negotiation and influencing skills, goal-setting, conflict resolution, staff development, and customer service skills.Excellent interpersonal, written, and oral communications skills.Strong management and leadership skills.Ability to adapt and respond to complex, fast paced, rapid growth/results oriented environment.Ability to communicate and work with physicians, nurses, managers, and other related departments.Ability to develop and effectively manage change as well as build consensus.Ability to work independently, exercise appropriate action and good business judgment.Ability to troubleshoot problems and follow up appropriately.Ability to simultaneously lead and manage multiple high priority projects and responsibilities.Ability to analyze and evaluate data and problems, develop alternative solutions and identify trends and patterns.
Key Job Responsibilities:Provides leadership, authority and direction to ensure accountability for programs, processes and initiatives required, enacted by or placed upon the Medical Staff Services Department. Directs and supervises Director, Medical Staff & Credentialing, Manager/Quality Integration, and Medical Staff Governance Coordinator to achieve goals.Facilitates and integrates the work of Patient Safety and Quality programs in collaboration with Regulatory Readiness, Risk Management, Chief Medical Officers, Chief Nursing Officers, Process Improvement & Innovation and Information Technology. Considers impact to, and promotes adoption by the Medical Staff and Allied Health Practitioners.In collaboration and with direction from system leadership, implements key strategic objectives for all aspects of health care quality improvement involving the Medical Staff and Allied Health Practitioners.Oversees all Medical Staff programs related to Credentialing, Privileging, Peer Review, Professional Practice Evaluations, and Professional Conduct for adherence to Medical Staff Governance and regulatory standards. Encompasses approximately 2,350 practitioners holding privileges at Memphis and Olive Branch hospitals.Serves as a subject matter expert. Researches, maintains, and shares knowledge of best practices and relevant trends for areas of oversight. Demonstrates understanding of regulatory standards and governance to lead associates in MSSD.Executes strategy by enacting objectives and operational tactics within areas of responsibility.Educates Medical Staff Executive Officers and Department Chairs of responsibilities when elected and provides consultation to solve problems with commitment to follow policies.Promotes confidentiality and protection of privilege afforded to practitioners per applicable laws.Advises Corporate HR on Allied Health Caregiver authorizations to resolve conflicts and improve processes.Prepares, reviews, and approves departments’ proposed annual budgets and explains significant variances to Sr. Vice President. Identifies areas of improvement or opportunity for clinical and financial improvement in areas throughout the hospital via comparative benchmarking and quality initiatives.Monitors and evaluates Associate performance and clarifies work expectations, and assists with goal setting; promotes cooperation among individuals and groups. Develops and implements processes through orientation, training and education to ensure that the competence of all staff members is assessed, maintained, improved and demonstrated throughout their employment.Develops MLH staff through orientation, training, and education in principles of process improvement. Promotes, maintains, demonstrates and communicates the value of self-development and enhancement of the professional competency of staff through quality improvement activities and other educational opportunities.
Supervision Provided by this Position:Oversees the Director, Medical Staff Services, Quality Improvement Specialists, Manager, Physician Quality, Physician Quality coordinator, and additional support staff.Active role in Administrative, Board and Medical Staff committee leadership throughout Methodist Healthcare related to Physician Quality and Performance Improvement.

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