Job Description:

At Houston Methodist, the Director Medical Staff Services position is responsible for providing leadership and support to the organized Medical Staff and serving as a liaison to the Medical Staff to promote and enhance communication and positive working relationships. The position is also responsible for establishing and maintaining continuity in the planning, development and implementation of standards, policies and procedures and operationalizing policies applicable to the Medical Staff Services department's function including: credentialing, Bylaws, rules & regulations, fair hearing plan and allied health professional manual, medico-legal issues, quality and administrative functions. The Director will be responsible for activities related to credentialing and privileges and will be responsible for all medical staff meetings ensuring effective and efficient use of time spent addressing medical staff issues and needs. Responsibility exists for assuring compliance and continual accreditation readiness, licensure with the Texas Department of Health and other licensing and regulatory standards relative to the Medical Staff organization. This position may also assume responsibility for other functions as directed by senior leadership. The Director position responsibilities include overseeing the activities of the department staff, ensuring quality, productivity, functional excellence and efficiency to accomplish strategic and operational objectives. In addition, this position is accountable for employee engagement, adequate staffing levels, budget development and compliance, staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and developing and implementing policies and procedures to ensure a safe and effective work environment. This position also ensures training, monitoring and operations initiatives are implemented which secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations. PEOPLE ESSENTIAL FUNCTIONS Directs, develops and implements strategic and operational/high level projects and processes either through independent/highly autonomous work or through the facilitation of work teams to enable the effective and efficient completion of objectives. Oversees management of and ensures development for staff to meet overall objectives in terms of quality, service and cost effectiveness. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Directs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees. Meets or exceeds threshold goal for department turnover and/or system metrics on employee engagement indicators: action readiness score, tier level. Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. Identifies opportunities and takes action to build strategic relationships between one's area and other areas, teams, departments, and units to achieve business goals. Drives the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed. Assists the Senior Leadership Team and Board of Trustees in developing and maintaining physician relations and services between the medical staff and the hospital to promote quality health care delivery and in response to community need. Develops, in conjunction with other system hospital leaders, a comprehensive orientation for new physicians and allied health professionals. SERVICE ESSENTIAL FUNCTIONS Oversees department operations, designated projects, schedules and activities as needed to ensure that goals or objectives are accomplished within the prescribed time frame. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction. Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department. Manages and coordinates medical staff and ad hoc committee meetings/minutes, to include tracking of attendance and maintenance of records in accordance with state and federal laws and all regulatory agency standards. Performs Medical Staff support functions that may include Emergency Room Call Schedule and Emergency Room Call Pay, Committee Pay, Stark Law compliance, etc. Manages existing physician services agreements and contracts and works as appropriate with legal and physicians to develop additional agreements necessary to support quality patient care and the hospital mission. Provides oversight and management of contracts and agreements relating to physician compensation, which includes but is not limited to the solicitation and receipt of time allocation reports. QUALITY/SAFETY ESSENTIAL FUNCTIONS Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines. Responsible for staff maintenance of credentials and competencies, per accrediting/ licensing agency and/or department guidelines as applicable. Employs a proactive approach in the optimization of safe outcomes and information systems by monitoring and improving the department workflow and enhancing operations, using peer-to-peer accountability and identifying solutions via collaboration. Implements process improvements utilizing tools such as lean principles. Role models situational awareness, using teachable moments to improve safety. Responsible for employee compliance to policies and procedures and performs associated actions upon non-compliance (i.e., licensure/certification compliance, focal point review requirements, disaster plan, in-services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.). Provides timely and concise follow-up on physician issues that become apparent. Coordinates timely communication and follow-through with appropriate hospital personnel and assists in the resolution of issues as appropriate. Coordinates resolution of physician issues in areas of peer review and physician behavior. Develops policies, procedures and systems to effectively operationalize the Medical Staff Bylaws, Rules and Regulations, Fair Hearing Plan, and Allied Health Professional Manual. Responsible for the organization, administration and follow up required to maintain continual accreditation and licensure readiness with regard to government/accreditation agency standards and regulations, licensure with the Texas Department of State Health Services, and other licensing and regulatory agencies. FINANCE ESSENTIAL FUNCTIONS Develops and manages department operational and capital budgets, approvals, and ongoing maintenance of the department(s), ensuring operation in a cost-effective manner. Proactively identifies and plans for capital needs related to current equipment and future department projects. Ensures staffing plans and schedules meet department needs that reflect understanding of the importance of cost-effectiveness. Creates department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications. GROWTH/INNOVATION ESSENTIAL FUNCTIONS Identifies and implements innovative solutions for practice or workflow changes to improve department, entity or system operations by leading unit projects and/or other department/ system-directed activities. Proactively leads task forces and committees. May represent HM at assigned community or professional organization meetings. Drives change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. Partners effectively with stakeholders as appropriate. Ensures own career discussions occur with appropriate management. Completes and updates the individual development plan (IDP) on an on-going basis. Conducts conversations with staff on their development and IDP. This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises. EDUCATION Bachelor's degree in healthcare administration, business administration, or other relevant field Master's degree preferred WORK EXPERIENCE Five years of experience in medical staff services in a similar hospital environment Three years of supervisory/management experience required LICENSES AND CERTIFICATIONS - REQUIRED N/A LICENSES AND CERTIFICATIONS - PREFERRED CPCS - Certified Provider Credentialing Specialist (NAMSS) and CPMSM - Certified Professional Medical Services Management (NAMSS) or CPHQ - Certified Professional in Healthcare Quality (NAHQ) KNOWLEDGE, SKILLS, AND ABILITIES Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially about activities impacting patient or employee safety or security Demonstrates the ability to interact with others in a way that gives them confidence in one's intentions and those of the organization Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one's own behavior to accommodate tasks, situations and individuals involved Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences Extensive knowledge of regulatory and accreditation agency requirements that impact department; stays abreast of industry changes Demonstrates highly effective communication skills-strong written communications and platform presentation abilities Ability to work effectively in a fast-paced environment Demonstrates flexibility and adaptability in the workplace Capable of leading teams/facilitating groups, building consensus and garnering highest confidence in professionalism and work product by senior leadership Ability to work under pressure and balance many competing priorities; highly responsive and solution/action oriented Proficiency in spreadsheet, word processing, and presentation software Maintains a positive and supportive attitude and demeanor Professional handling of exposure to confidential/sensitive information Thorough knowledge of Medical Staff Services functions and procedures A working knowledge of medical terminology; the functions of other hospital departments; and management principles and practices Strong ability to evaluate and develop effective process improvements to enhance efficiency of operations Strong facilitation and presentation skills Solid knowledge of State and Federal law relating to medical staff operations, the Health Insurance Portability and Accountability Act of 1996, regulatory/accreditation agency standards and elements of performance, Medical Staff Bylaws and Rules and Regulations, and Continuing Medical Education Must demonstrate a high level of leadership skills to effectively interface between the hospital, medical staff, administration and Board SUPPLEMENTAL REQUIREMENTS WORK ATTIRE Uniform No Scrubs No Business professional Yes Other (department approved) No ON-CALL* *Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below. On Call* Yes TRAVEL** **Travel specifications may vary by department** May require travel within the Houston Metropolitan area Yes May require travel outside Houston Metropolitan area Yes Company Profile: Since its founding in 1919, Houston Methodist Hospital has earned worldwide recognition. Houston Methodist Hospital is affiliated with the Weill Medical College of Cornell University and New York-Presbyterian Hospital, one of the nation's leading centers for medical education and research. In 2022, U.S. News & World Report named Houston Methodist Hospital to its prestigious Honor Roll for the sixth time. Also, in this year's rankings, Houston Methodist Hospital was named the No. 1 hospital in Texas for the 11th year in a row. Houston Methodist Hospital directs millions of research dollars into patient care and offers the latest innovations in medical, surgical and diagnostic techniques. With 946 operating beds, 85 operating rooms and nearly 8,500 employees, Houston Methodist Hospital offers complete care for patients from around the world. Houston Methodist is an equal opportunity employer inclusive of women, minorities, disabled persons and veterans.