Yale New Haven Health System


    Job Locations US-CT-New Haven
    Job ID
    Position Type
    Full Time Benefits Eligible
    Scheduled Hours
    Work Schedule
    Work Days
    Work Hours
    8:00 - 4:30; OCCASIONAL 7:00 A.M. MEETINGS AND 5:00 P.M. MEETINGS.
    Work Shift
    Requisition ID
  • Overview

    To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values—integrity, patient-centered, respect, accountability, and compassion—must guide what we do, as individuals and professionals, every day.

    Under the direction of the Executive Director, Medical Staff Services and consistent with the policies and procedures of the YNHHS Medical Staff Administration Department, the Director is responsible for the day to day management of the functions of medical staff administration at Yale New Haven Hospital and, as applicable, other health system affiliated hospitals.  Responsibilities include managing, organizing and supervising the medical staff services functions and maintaining compliance with applicable standards of The Joint Commission, National Committee on Quality Assurance, Federal and State Regulations and the relevant facility Medical Staff Bylaws and Rules & Regulations.  Responsible for the oversight, management and work of staff at the New Haven and other sites as directed.  Ensures the effective use of resources, staff and functions as a member of the YNHH team as well as the larger YNHHS Medical Staff Administration Department.



    1. Supervises, assigns work and directs staff in performance of job functions. Responsible for personnel management. 
    2. Participates directly in and supports the Executive Director in the process of developing and implementing consistency among YNHHS affiliated hospitals’ medical staff policies, procedures, bylaws  and related documents as well as overall practice and operation of the local Medical Staff Administration Department.  Works collaboratively with other YNHHS Medical Staff Administration team members to develop and implement YNHHS system approach to credentialing and privileging.  Responsible for engaging local staff accordingly. 
    3. Manages the reappointment application processes to ensure that work is completed consistent with regulatory requirements and, YNHHS policies and procedures and the relevant Medical Staff Bylaws/Rules & Regulations.  Coordinates processing with staff at other local sites to eliminate duplicative efforts by staff and applicants.
    4. Ensures that applications are processed and completed within established time frames and deadlines based on Department policies, stated expectations and regulatory requirements
    5. Ensures appropriate “posting” of privileges for accessibility throughout YNHH.  Notifies medical staff of reappointment decisions, privileges and any associated relevant information in writing in a timely manner.
    6. Maintains all YNHH medical staff members in NPDB “proactive disclosure service” and ensures that enrollment is discontinued accordingly for inactivated medical staff.
    7. Monitors TJC, DPH and CMS for changes to requirements regarding medical staff, alerts Executive Director accordingly.  Develops recommendations regarding policy, procedure or Bylaw changes to ensure compliance, implements and educates staff accordingly.
    8. As directed, researches and develops policies, procedures & criteria for privileging in conformance with the Medical Staff Bylaws/Rules & Regulations, Joint Commission standards and YNHHS guidelines.
    9. Responsible for working with relevant Medical Staff leaders in the development of new and modification of existing privilege delineations including conducting appropriate research in advance to identify industry standards.  Ensures that recommended changes are presented and escalated through the relevant medical staff committees.  Posts final version accordingly in PCCB and educates all staff regarding changes.
    10. Responsible for ensuring that information obtained in the credentialing process is appropriately handled and maintained to retain peer review protection under CT State Law.
    11. Responsible for ongoing monitoring of medical staff against requirements as stated in the Bylaws and notification of Medical Staff in a timely manner with respect to expirable licenses and certifications consistent with local expectations and in adherence with Medical Staff Bylaws.  This includes, but is not limited to:  state license, DEA certification, state narcotic certification, malpractice coverage, local practice coverage, exclusion from participation in governmental payor programs, arrests or other issues with external agencies or the law, satisfaction of appropriate board certification and re-certification requirements based upon specialty area of practice, etc. Alerts Executive Director and other Department management staff of any concerns identified and follows up as directed.
    12. In collaboration with the appropriate Department staff, ensures that medical staff  performance data  (including, but not limited to, Ongoing Professional Practice Evaluations (OPPE) and Focused Professional Practice Evaluations (FPPE)) is incorporated and considered in the reappointment process as required by The Joint Commission and relevant Medical Staff Bylaws.
    13. Demonstrates appropriate stewardship of financial resources including appropriate management of overtime.  Works with the YNHHS Executive Director to identify and manage opportunities for cost savings.  Works with staff to plan work load against deadlines and committee obligations to prevent incurring overtime expense.
    14. Supports YNHH CMO in the oversight of medical staff compliance with requirements set forth in the relevant Medical Staff Bylaws Rules & Regulations as directed and appropriate.
    15. In collaboration with the Executive Director and local committee Chairs, prepares and distributes agenda and materials for the YNHH Medical Executive Committee (MEC) , Medical Executive Administrative Committee (MEAC), Patient Safety & Clinical Quality Committee of the Board of Trustees (PSCQ), Finance Committee, Nominating Committee and other Committees as directed.  Consults with appropriate individuals as directed to set the agenda.
    16. Maintains and manages committee membership for YNHH MEC, MEAC, PSCQ, Bylaws, Nominating and Finance Committees including monitoring in accordance with the bylaws to ensure that appropriate changes are made to participation in these committees in a timely manner.
    17. Ensures timely distribution of agenda and materials in a manner consistent with local practice.    Responsible for ensuring that meetings are scheduled to accommodate key participants and attendees are appropriately notified of the meeting schedule and details.  Attends meetings, takes minutes and follows up accordingly as directed.  Maintains a tracking system to ensure that agenda items are included consistent with regulatory requirements and direction of the Executive Director, YNHH CMO and relevant medical staff officers
    18. Manages the process of the collection of medical staff dues consistent with the requirements of the Medical Staff Bylaws.  Ensures that funds are deposited accordingly and, upon required approval, distributed based on the recommendation of the YNHH Finance Committee and MEC. 
    19. Responsible for understanding the functionality of MSOW and its associated components including PCCB and for the oversight and education of Department staff in their utilization of this system.  Responsible for the accuracy and integrity of data entered by self and staff relative to the applicable hospital/s.  Ensures that data identified as critical is consistently entered and entered in a timely manner.  Identifies any reports that are necessary for the local site/s and works with the YNHHS System Implementation Manager to develop these as needed.  Responsible for running and distribution of reports needed at the local site/s.  Educates local hospital staff on how to access “self serve” reports as appropriate.
    20. Responsible for the local implementation of workflow, policy/procedure and system changes, modifications or enhancements as directed to improve efficiency and achieve consistency across YNHHS
    21. Facilitates an atmosphere of collaboration and team oriented interpersonal relationships, communication flow and information sharing among local and YNHHS staff and Hospital departments.
    22. Consistently demonstrates excellence in modeling the Standards of Professional Behavior to all staff and encourages all staff to do likewise. Re-educates and counsels staff accordingly.  Ensures a customer service orientation with regard to all interactions.  Follows through in a timely manner on requests. 
    23. Responsible for representing the Department in interacting with representatives from regulatory organizations to demonstrate compliance with credentialing and privileging requirements and matters of medical staff administration as applicable based on local hospital practice.  Prepares files and double checks documentation accordingly in advance to evidence an organized and thorough process.  Arranges appropriate back up coverage in advance when not personally available.  Plans personal schedule to the greatest extent possible to ensure participation.   This includes participation in regulatory surveys with TJC (including specialty specific surveys), the State of CT Department of Public Health (DPH) and DPH acting as the Centers for Medicare and Medicaid Services (CMS).  In consultation with the Executive Director, develops and implements any changes prompted by regulatory reviews in compliance with the relevant medical staff bylaws and YNHHS policies and procedures. 
    24. Performs other duties as assigned or directed to ensure efficient and effective operation of the department/unit.



    Bachelor’s degree in liberal arts, health care administration, business administration or other relevant field required.  Master’s degree in health care administration, public health, business administration or other related field strongly preferred.



    5-7 years hospital or health system medical staff services experience required including evidence of management of staff.



    Must be able to independently plan, develop and implement policies, procedures, programs/services. Strong analytical ability and problem solving skills. Exemplary organizational, verbal/written communication skills; proven experience and skill in physician relations/a ability to perform analyses and make appropriate recommendations; high level of orientation to detail and accuracy; ability to enforce and maintain adherence to established policies and procedure sunder significant pressure; must be highly customer service oriented and be able to work as a team members in a fast paced environment. Thorough knowledge of TJC and NCQA standards relative to medical staff matters.  Proficiency in Word, EXCEL and PowerPoint required.



    Current certification by the National Association of Medical Staff Services (NAMSS) as a “Professional in Medical Staff Services Management “ or “Provider Credentialing Specialist”  is required.



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