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Job Summary

Provides administrative management, leadership, and direction of the Medical Staff Services (MSS) office and MSS initiatives to ensure ongoing accreditation by The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), National Commission for Quality Assurance (NCQA), URAC, state and federal regulators, and all managed care payers. Manages and coordinates all appointment/reappointment, and credentialing and privileging processes within Michigan Medicine, ensuring strict compliance with applicable rules and regulations of the accrediting bodies and with Michigan Medicine policies.  Works closely and effectively with the Administrative Director for Medical Staff Services, the Chief Medical Officer, Chief of Staff, Chair of the Credentialing and Privileging Committee, hospital leadership, clinical departments, Medical School, and the Office of General Counsel in order to provide required services.

Ability to analyze, compare, and evaluate various courses of action, and have the authority to make independent decisions on matters of significance, free from immediate direction, within the scope of their responsibilities. Primary activities and decision making authority are predominantly performed independently affecting business operations to a substantial degree. 

Continually reviews processes to assess overall compliance with accrediting bodies; develops and implements policies, procedures and data collection to facilitate this ongoing effort. Works closely with clinical departments, and physician faculty to identify and implement supportive or corrective processes to manage accreditation requirements.

Responsibilities*

Leadership:

Provide strategic leadership to MSSOversight for performance improvement initiatives and activitiesProvide input on budget/financial objectivesApproval of expendituresLong-term maintenance and support for affiliate credentialing, health plan audits, and vendor contractsCredentialing and privileging initiativesNew privilege/new technology requestsRepresent MSS at routine and ad hoc committees

Operations:

Manage day-to-day operations of permanent staff that include credentialing specialists, database administrator, project manager, and administrative assistantMakes decisions on hiring, promotions, disciplinary actionManage and monitor staff workloadMonitors staff performanceDeveloping and managing staff performance improvement plansSet team goalsProcedure manual development and ongoing maintenanceStaff performance metric development and reportingTimekeepingPosition request, posting, and hiring processes

Performance and Process Improvement:

Leads and participates in LEAN weekly huddlesUse Lean in Daily Work methodology for process improvementMonitors key metrics that drive performanceMonitoring performance goals of direct reportsMaintaining and monitoring all staff metrics at the individual and team levelEstablishes targets and thresholds for performanceEngages staff in improving performanceDevelops and documents standard work for all important business processes

Policy Management:

Creation, maintenance, and updates of Medical Staff Services policiesProvides input on relevant Bylaws updates/revisions related to Credentialing and PrivilegingAdvises on policy interpretationCollaborates with others on development of health system-wide policiesMedical Staff policy management (coordinating with external departments)

Credentialing and Privileging:

Internal file audit for accuracy and compliance with regulatory requirementsLeads initiatives to move to a paperless credentialing processStaffing Michigan Medicine Credentialing Committee, coordinating agenda setting and managing follow-up itemsDocument management for all MSS formsDelegated credentialing under affiliate contract for UM practitioners practicing at affiliate sitesPrivileging document development and oversight of ongoing document maintenanceManage appropriate escalation of findings during the credentialing process, coordinating with the Chief of Staff, Associate Chief of Staff for Credentialing and Chair of Credentialing and Privileging Committee, Administrative Director of MSS, Department Chair, or Service Chief when appropriate

Regulatory Readiness:

Coordinates delegated payer audits for all contracted health plansParticipation in TJC, CMS, and state licensing surveys. This requires the ability to travel to the main hospital from MSS office as needed. If working remotely, requires travel to Michigan Medicine for announced and unannounced surveys.Works closely with the Office of Clinical Affairs on identified issues Managing performance improvement plans/corrective action plans if needed Ensures appropriate disciplinary action and sanctions are reported to outside agencies

Affiliations, Acquisitions, and Mergers:

Acts as MSS lead for due diligence review to identify gaps and best practices specific to credentialing and privileging for new healthcare acquisitions, contracts, or affiliations Maintains ongoing due diligence with affiliates ensuring alignment with current policies and procedures Development and maintenance of delegated credentialing contracts and telemedicine agreementsLong-term maintenance of affiliate relationshipsRepresentation on affiliate credentialing committees 

Finance, Budget, and Contracting:

Evaluates key financial, budgetary and other metrics related to operationsProvides information, trends or other conditions that may affect operations or budget planningParticipates in the development of FTE budgetary expenses, operational expenses and capital budgets in coordination with the Administrative Director and Office of Clinical AffairsManages current vendor contracts for MSSMSS lead for delegated facility and payer credentialing contract development and review

Travel

Approximately 10% travel for offsite meetings and conferencesRequired Qualifications*Bachelor's degree in Business, Public Health, Administration or other related field.  CPMSM (Certified Professional Medical Staff Management) certification from NAMSS or certified within five years of employmentConsiderable knowledge of CMS, TJC, NCQA, and URAC rules and regulations as they relate to hospital accreditation, credentialing, and privileging  Ability to commit to and meet deadlines, while not compromising quality  Must be extremely detail oriented and able to handle multiple projects, prioritizing workload to maximize efficiency  Outstanding verbal and written communication skills, as well as advanced organizational skillsStrong record of working effectively with staff in a diverse environmentDesired Qualifications*Master's degree in Business, Public Health, Administration or other related field, or an equivalent combination of education and experienceAt least 5 years' experience in management with supervisory experienceExperience managing a Medical Staff Office (MSO), Credentialing and Privileging Office, or Credentials Verification Organization (CVO) Trained in LEAN principles for healthcareExperience with CACTUS from symplr softwareKnowledge and understanding of the University of Michigan Health System policies and proceduresExperience in an academic medical centerModes of Work

Positions that are eligible for hybrid or mobile/remote work mode are at the discretion of the hiring department. Work agreements are reviewed annually at a minimum and are subject to change at any time, and for any reason, throughout the course of employment. Learn more about the work modes.

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days.  The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO Statement

The University of Michigan is an equal employment opportunity employer.