NASH HOSPITALS, INC.  ROCKY MOUNT, NC
Job Description and Performance Criteria
POSITION TITLE
Medical Staff Support Coordinator
POSITION CODE
629
DEPARTMENT
Medical Affairs
ENTITY
NGH
MANAGEMENT SIGNATURE
Rosario Guarino, MD
EFFECTIVE DATE
1
POSITION SUMMARY: Primary responsibility is Medical Staff and provider membership. Coordinates credentialing and privileging functions for the Medical
Staff, other providers, and their employee. Provides general administrative and secretarial support to the Medical Staff President and the various Medical Staff
departments and committees.
EDUCATION, CREDENTIALS AND TRAINING:
Required:
Completion of formal educational curriculum for Executive Secretaries or Administrative Assistants, or the equivalent. Proficient in the use of
keyboard and basic computer applications. Proficient in the use of Microsoft Office software..
Preferred:
Certified Medical Staff Coordinator. Experienced with Privplus and other credentialing software.
EXPERIENCE: A minimum of two years of secretarial experience is required; medical staff credentialing experience is preferred.
ADDITIONAL SPECIALIZED KNOWLEDGE/SKILLS: Incumbent must demonstrate an ability to apply age-appropriate principles of communication during
interaction with others. Incumbent must demonstrate competence per the position’s Skills Checklist before being allowed to perform independently.
ORGANIZATIONAL RELATIONSHIPS:
Supervises:
None
Reports To:
SeniorVice President, Medical Affairs / Chief Medical Officer
FLSA STATUS:
Exempt
Job Title: Medical Staff Support Coordinator
Job Code: 629
Department: Medical Affairs
Entity: NGH
OSHA Category
1. Tasks that involve exposure to blood, body fluids or tissues.
2. Tasks that involve no exposure to blood, body fluids or tissues. However, because of the nature of the work, the performance of Category 1 tasks may be necessary.
X
3. Tasks that involve no exposure to blood, body fluids or tissues, and Category 1 tasks are not a condition of employment.
Indicate by the frequency codes below, the approximate amount of time that the following are required of persons in this job.
1 - Never (0% of the Time)
2 - Rarely (Approximately less than 3% of the Time)
3 - Occasionally (Approximately 3-10% of the Time)
4 - Routinely (Approximately 11-33% of the Time)
5 - Frequently (Approximately 34-66% of the Time)
6 - Continually (Approximately 67-100% of the Time)
PHYSICAL REQUIREMENTS
1
1
1
1
1
1
Patient Care Functions
Push or pull occupied wheelchairs or stretchers
Assist in lifting/moving patients to and from stretchers or beds
Move/Position patients while in their beds
Assist/Support patients during ambulation
Restrain patients from hurting themselves/others
Other:
5
3
2
1
1
1
Non-Patient Pulling, Pushing, Lifting or Carrying
Less than 10 pounds
11-25 pounds
26-50 pounds
51-75 pounds
76-100 pounds
More than 100 pounds
6
3
2
2
2
1
2
2
6
2
2
General Activities
Sitting
Walking
Standing
Bending
Stooping
Climbing
Kneeling
Twisting
Keyboard operations
Working in awkward positions
Working in fixed, straining positions
Other:
Hand Dexterity
5
2
5
Simple grasping
Power grasping
Fine manipulation
5
6
6
3
1
3
3
Visual Acuity
Normal reading
CRT viewing/reading
Moderate distance acuity: 2 feet to 20 feet
Long distance acuity: More than 20 feet
Looking through a microscope
Making color distinctions
Using depth perception
Other:
2
6
1
3
Hearing Acuity
Low level sounds; below normal speaking voice
Normal speaking level sounds
Sounds through stethoscope or other medical instrument
Sounds through non-medical instruments/equipment
Other:
HAZARDS
1
1
2
1
2
2
2
1
2
2
2
2
Potentially Hazardous Working Environments:
Unusually dirty/dusty work spaces
Extreme temperatures (hot or cold)
Extreme loud noise
Wet/Slippery walking surfaces
Low lighting
Noxious odors/fumes
Poor ventilation
Other:
Potentially Hazardous Working Situations:
Work from ladder/scaffold
Handle needles, knives or other sharp objects
Operate equipment/tools that have hot exposed surfaces that can burn skin
Operate equipment/tools with exposed moving parts that can cut or crush fingers, etc.
Handle toxic, volatile or corrosive substances
Reaching
3
2
4
1
1
At shoulder level
Above shoulder level
Below shoulder level
Employee Name
Job Title
Medical Staff Support Coordinator
Work on, or handle, live electrical wiring or components with real potential of shock or electrocution
electrocutionn
Physically interact with violent patients or visitors
Other:
Department
Medical Affairs
Job Code
629
Entity
NGH
Review Date
PROCESS ACCOUNTABILITIES
•
•
•
•
•
Coordinates the physician credentialing process for new applicants and reappointments, and prepares, processes or maintains associated hard copy and computer system documents and
files.
Processes initial applications for Provisional Appointments
Verifies and presents physician applications through the required medical staff committee process
Maintains confidential credentialing files on all medical staff reflecting current status (category, board certification, privileges, attendance records and profiles)
Maintains current license and liability coverage renewals
Generates annual CME, attendance and other tracking reports using PrivPlus software system
a. Ensures that requirements for medical staff appointments, reappointments and credentialing are met in accordance with prescribed procedures, JCAHO and other regulatory requirements, and
designated time frames.
b. Ensures that designated medical staff files are maintained in an accurate and up-to-date condition, and are complete in their requirements.
c. Ensures that physicians are notified of renewal dates for licenses and liability insurance starting 60 days in advance of expiration date, and following through as needed, until renewal is accomplished.
d. Competently utilizes PrivPlus software for designated functions, without assistance.
DEVELOPMENTAL NOTES AND OTHER COMMENTS:
•
•
•
•
•
Provides administrative support to the medical staff departments and committees.
Maintains master calendar of medical staff department and committee meetings
Notifies relevant persons of meeting schedules and schedule changes
Establishes meeting agendas, to include necessary background information, and distributes
Makes meeting arrangements
Maintains minutes of meetings
a. Maintains master calendar in an accurate and up-to-date condition.
b. Ensures that agendas are established in the proper format, are in keeping with the Chairs’ instructions, and are distributed to relevant members on a timely basis.
c. Effectively coordinates the detail arrangements for meetings, ensuring that such things as notifications, scheduling, agendas, room/equipment set-up and refreshments/meals, and other requirements
are accomplished on a timely basis, following through as needed to resolve any problems.
d. Properly researches and/or organizes materials, data or files for meetings, as instructed.
e. Effectively prepares/presents reports, and or communicates information pertinent to meeting agenda, when assigned.
f. Records, transcribes and distributes minutes of designated meetings, using appropriate format, and ensuring accuracy and completeness of the information documented.
g. Ensures that all original minute notebooks, and their attachments are complete and properly organized, on an ongoing basis.
h. Ensures that any issues requiring follow-up that are referenced in the minutes are accomplished, or are communicated to party responsible for follow-up action.
DEVELOPMENTAL NOTES AND OTHER COMMENTS
Communicates with medical staff and external agencies concerning medical staff activities and operations.
Stays abreast of, and communicates, accurate and up-to-date information pertaining to accreditation requirements, legal requirements, by-law provisions, rules, regulations and other related
information, seeking clarification as needed to ensure accuracy of information exchange.
Conveys and releases information only as authorized.
Establishes and maintains an effective working relationship with all persons with whom collaboration is required.
Responds promptly to requests for assistance or information from medical staff or external agency representatives.
Ensures that any pertinent updates or informative materials are distributed to appropriate persons on a timely basis.
Promotes effectiveness and acceptability of actions and decisions, by ensuring that adequate, accurate, relevant and timely documentation is established and maintained to chronicle situations, events
and actions/decisions made.
Keeps VP, Medical Affairs informed regarding critical incidents and pertinent issues.
Communicates positively, directly, clearly, accurately and timely in all interactions.
Demonstrates ability to express self in all areas of communication (verbal, written, non-verbal) and utilizes effective listening and questioning techniques.
DEVELOPMENTAL NOTES AND OTHER COMMENTS
•
•
•
Accomplishes a variety of other support services for the Medical Staff President, and department/committee Chairs.
Assists in updating medical staff policies and procedures
Assists in preparing documents for accreditation
Prepares correspondence and other documents
a. Provides substantiated and relevant input into the establishment/update of medical staff policies and procedures, and documents for accreditation, and/or follows instructions for their preparation, as
requested.
b. Creates correspondence and other documents from written draft, dictation or verbal instructions, using word processing software, ensuring accuracy in format, spelling, content, grammar and
punctuation.
c. Initiates responses to routine and simple inquiries/correspondence for Medical Staff President/Chair signature, when appropriate, so as to free up their time for more important responsibilities.
d. Ensures that a photocopy of outgoing documents is made and appropriate filed, as warranted.
e. Establishes and maintains administrative systems for the collection, storage, processing, dissemination and communication of information relating to medical staff activities, ensuring that issues of
security, accessibility and confidentiality are adequately addressed.
DEVELOPMENTAL NOTES AND OTHER COMMENTS
Acquires age-specific knowledge necessary to provide appropriate service and communications.
Demonstrates knowledge of growth and development over the entire life span of a person.
Appropriately uses age-specific concepts when communicating with employees, visitors and others.
DEVELOPMENTAL NOTES AND OTHER COMMENTS
Participates in maintaining designated equipment and work areas.
Properly operates and maintains departmental equipment/machines in accordance with procedure or specifications, promptly reporting malfunctioning items to supervisor.
Participates in ensuring that sufficient and necessary supplies are acquired on a routine and emergency basis, in accordance with procedure.
Ensures that work area is maintained in a neatly organized and clean condition.
DEVELOPMENTAL NOTES AND OTHER COMMENTS
Participates in quality assurance and quality improvement activities.
Effectively performs data collection, analysis and idea generation pertinent to the department’s quality assurance and quality improvement programs, on an on-going basis, without prompting.
DEVELOPMENTAL NOTES AND OTHER COMMENTS
Takes an active role in self development.
Participates in self evaluation by making notes/comments in the Accountabilities section of the annual review, updating skills checklist, and mutually setting professional goals for achievement with
the manager.
Always reads and signs new policies, procedures, CQI materials and memos.
Participates in, and assures that, documentation of own continuing education and self development activities is current and valid by signing rosters and submitting copies of CE certificates for
transcript.
Recognizes self deficit in knowledge, skills, or decision making, and seeks validation/guidance from appropriate resources when indicated.
Stays abreast of professional developments through reading, attending seminars, professional affiliations and networking.
DEVELOPMENTAL NOTES AND OTHER COMMENTS
Performs other duties as needed.
Serves and actively participates on teams/committees as appointed.
Accomplishes routine and non-routine miscellaneous assignments in accordance with procedure or instructions, and time frames.
DEVELOPMENTAL NOTES AND OTHER COMMENTS
KEY PERFORMANCE OUTCOMES
Ensures that requirements, documentation and files for medical staff appointments, reappointments and credentialing are met and
maintained in accordance with prescribed procedures, JCAHO and other regulatory requirements, and designated time frames, with no
more than 1-2 noted exceptions per year, and no exceptions resulting in privileges being inappropriately granted or denied due to
error/omission made by Medical Staff Coordinator.
Wt
50
Exceeded
Standard
Met
Standard
Did Not
Meet Std
Accomplishes all responsibilities associated with the medical staff department/committee meetings (master schedule, agendas, meeting
preparations/notifications, research/organization of materials, reporting, minutes) in accordance with procedure or specifications, and time
frames, with no more than 1-2 valid complaints, or otherwise noted deficiencies/exceptions per year.
POINTS EARNED - KEY PERFORMANCE OUTCOMES
50
minus
0
Justifications for any of the above criteria which is “Exceeded” or “Not Met” and Action Plans for any criteria “Not Met” (Reference item number along with notes)
TOTAL POINTS EARNED BEFORE EXTRA CREDIT
Percent
Awarded
EXTRA CREDIT
Points
Awarded
State Reason(s) for Any Extra Credit Awards: (Max Award = 10% of Points Earned; 5% Max Per Reason)
.
POINTS EARNED - EXTRA CREDIT
SCORING
Add Up the Points Earned in Each Category
TOTAL POINTS EARNED
Determine Total Points Available
Total Starting Weight
Subtract Weights of Criteria that are “Not Exceedable”
Subtract Weights of Criteria that are “Not Applicable”
TOTAL POINTS AVAILABLE
Divide Total Points Earned by Total Points Available
EMPLOYEE’S SIGNATURE
Employee’s Signature indicates only that s/he has seen the
performance review document. It does not imply agreement
or disagreement with the contents.
EVALUATOR’S SIGNATURE and TITLE
(If not the Department Manager)
DEPARTMENT MANAGER’S SIGNATURE
FINAL SCORE
DATE
VICE PRESIDENT’S /PRESIDENT’S SIGNATURE
(If Score is Below .2 or Above .8)
Rosario Guarino, MD SVP, CMO
EMPLOYEE COMMENTS/GOALS:
TO BE COMPLETED BY HUMAN RESOURCES:
_________%
(Note any Top of Scale restrictions; Note status of delays due to failure to meet Basic Criteria)
Award Earned:
Number Pay Periods Credited: __________
FINAL AWARD:
__________%
Date of Implementation:
__________