Medical Staff Services and Cvo Supervisor

GENERAL SUMMARY:

Responsible for overseeing the credentialing, privileges, and peer review processes within the health system. Ensures compliance with regulatory standards, accreditation requirements, and organizational policies while supporting medical staff governance. Leads a team responsible for verifying provider qualifications, maintaining credentialing databases, and facilitating peer review activities to uphold high-quality patient care and provider accountability.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Supervises the credentialing and privileging process for all physicians and allied health providers, ensuring timely and accurate verification of qualifications, licenses, certifications, and professional history.

3. *Maintains compliance with accrediting bodies such as The Joint Commission (TJC), National Committee for Quality Assurance (NCQA), The Center for Improvement in Healthcare Quality (CHIQ), Centers for Medicare & Medicaid Services (CMS), and state/federal regulations, as well as medical staff bylaws and policies.

4. *Oversees the management of credentialing databases and software, ensuring data accuracy and integrity.

5. *Facilitates the peer review process, ensuring a systematic evaluation of provider performance and quality of care for Bryan Medical Center and serves as a resource to the other entities on peer review processes.

6. *Works closely with medical staff leadership to coordinate case reviews, investigations, and performance management initiatives.

7. *Acts as a key resource to the Credentials and Peer Review Committees Chairs and membership; as well as, the Medical Staff Division and Department Chairs who are performing credentialing and peer review duties.

8. *Supervises and mentors credentialing and peer review staff, providing training, guidance, and performance evaluations.

9. Ensures team productivity, accuracy, and adherence to established procedures and timelines.

10. Develops and implements process improvements to enhance efficiency and effectiveness of credentialing and peer review functions

11. Stays updated on industry regulations and accreditation standards to ensure organizational compliance.

12. Assists in developing, updating, and enforcing credentialing and peer review policies and procedures.

13. Maintains confidentiality and integrity of peer review documents, reports, and processes in compliance with legal protections and regulatory requirements.

14. Prepares reports and documentation for audits, accreditation surveys, and medical staff leadership.

15. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

16. Participates in meetings, committees and department projects as assigned.

17. Performs other related projects and duties as assigned.

*(Essential Job functions are marked with an asterisk "*". Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES:

1. Knowledge of basic Medical Center operations and functions of the medical staff.

2. Knowledge of state, Joint Commission, and federal regulatory accreditation requirements.

3. Knowledge of computer hardware equipment and software applications relevant to work functions.

4. Knowledge of organizational and human resource management standards and practices.

5. Knowledge of performance improvement practices.

6. Knowledge of management and leadership principles and practices.

7. Skill in conflict diffusion and resolution.

8. Ability to communicate effectively both verbally and in writing.

9. Ability to perform crucial conversations with desired outcomes.

10. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.

11. Ability to problem solve and engage independent critical thinking skills.

12. Ability to maintain confidentiality relevant to sensitive information.

13. Ability to prioritize work demands and work with minimal supervision.

14. Ability to make operational and management decisions in response to changing conditions.

15. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Bachelor's degree in administrative or health care field or in lieu of degree, five (5) years of equivalent work experience required. Minimum of three (3) years of experience in medical staff credentialing and peer review with minimum of one (1) year in a supervisory role required.

OTHER CREDENTIALS / CERTIFICATIONS:

None

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a

negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human

body.