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Quality and Medical Staff Services Specialist Full Time

Quality and Medical Staff Services Specialist - Full Time Days; Exempt. Monday - Friday

This position serves as a liaison and provides support to the Quality department work specific to Medical Staff Services, Accreditation and Regulatory, and Patient Safety program. Coordinates execution of related activities to insure goals and objectives specified are accomplished in accordance with prescribed priorities, time limitations, and regulatory guidelines.


Specific Knowledge, Skills, and Capabilities:
- Ability to gather and summarize data for reports, find solutions to various administrative problems, and prioritize work.
- Adept at composing, typing and proofing materials, establishing priorities and meeting deadlines.
- Excels in a fast-paced environment with demonstrated ability to independently juggle and prioritize multiple, competing tasks and demands and to seek supervisory assistance as appropriate.
- A professional appearance and communication skills essential.
- Ability to professionally handle sensitive and confidential situations and information.
- Highly effective interpersonal, verbal, and written communication skills.
- Able to work independently for extended periods of time to meet deadlines.
- Types and designs general correspondences, memos, charts, tables, graphs, etc.
- Proofreads copy for spelling, grammar, and layout, making appropriate changes.


Essential Functions:

Medical Staff Services
- Monitor Initial, Reappointment and Additional Privilege requests processed by HealthPartners Credentialing Services Bureau (CSB). Ensure CSB meets site & accreditation requirements.
- Track physician appointment and reappointment files in progress to ensure timely completion.
- Maintain and monitor NPDB database.
- Organize and analyze credentialing information received. Review for completeness; pull quality information & follow-up on missing information; trouble shoot issues. Prepare files for approval process.
- Completes data gathering for the OPPE/FPPE process for all credentialed providers not to exceed every 8 months. Distributes OPPE documents to medical directors for review. Maintain files of all completed OPPE/FPPE documents.
- Coordinate agendas/minutes/meeting materials and attend Medical Executive committee.

Regulatory and Accreditation
- Monitors regulatory and accreditation trends and follow through on action plans and activities addressing areas of non-compliance
- Coordinates and participates in accreditation and regulatory surveys
- Coordinates/organizes all regulatory documents to ensure survey readiness.
- Coordinates and independently manages routine meetings for the team and chapter leaders
- Regular attendance at MNMarc and RegFIT

Patient Safety
- Conducts and provides reports related to patient or clinical systems tracers and on-going rounding
- Facilitates and records proactive risk and safety assessments in coordination with department leaders to identify opportunities of improvement in patient safety preventive measures and mitigation of adverse events.
- Manages users within the electronic safety reporting system
- Collaborates in the implementation of the organization’s Culture of Safety survey
- Assists with coordination of patient safety week
- Supports RCA/Case investigations in a confidential manner.
- Performs audits and data entry upon request.
- Attend SafetyFIT as alternate when Director unable to attend


Required Qualifications:
- Associate's degree
- Three years of increasingly responsible administrative experience required
- Experience in at least one of the following: hospital quality, data reporting, accreditation and/or credentialing


Preferred Qualifications:
- Bachelor's degree
- Current Credentialing Specialist Certification (CPCS) or Certified Professional Medical Services Management (CPMSM)



Located just off I-94 between the Minnesota and Wisconsin border, you’ll find exceptional, personalized care at Hudson Hospital & Clinic. With our internationally recognized healing arts program, we invite you to experience Hudson Hospital & Clinic warm, comforting healing environment. As part of HealthPartners family of care, we offer access and choice to our patients and focus on quality health care for the communities we serve.

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