MG Dir Med Staff Credentialing

Baltimore, MD
May 08, 2018
Jun 01, 2018
Contract Type
Full Time
What You Will Do:

Treating over 330,000 patients every year, the University of Maryland Medical Center (UMMC) is at the vital core of Maryland’s health care system and community. We’re known for our prestigious expertise in innovative research and education, along with the talented staff and advanced centers that make it all possible. The R Adams Cowley Shock Trauma Center, the world’s first center dedicated to trauma, treats more than 7,500 critically injured patients a year with an incredible 97 percent survival rate. We also have one of the nation’s largest kidney and pancreas transplant programs at The Joseph and Corinne Schwartz Division of Transplantation, home to Maryland’s first steroid-free protocol and pancreas/kidney transplant. From our National Cancer Institute-designated UM Marlene and Stewart Greenebaum Cancer Center to The University of Maryland’s Children’s Hospital, one of the largest pediatric centers in the state, we are dedicated to saving and transforming lives.

1. Leads organizational effort related to ongoing Joint Commission compliance and continuous survey readiness through oversight of TJC chapter teams activities and monitoring of survey readiness metrics.
2. Acts as Survey Coordinator for all Joint Commission and CMS surveys and ensures required survey response activities (ESC / MOS) are completed and submitted correctly within required timeframes.
3. Facilitates annual organizational completion and submission of TJC Periodic Performance Review (PPR), and required Evidence of Standards Compliance (ESC) / Measure of Success (MOS) follow-up activities.
4. Manages the processes related to ongoing tracer and safety round activities to include development of tools, education of teams, and use of results to ensure ongoing compliance.
5. Provides supervision and direction to the Credentialing office to include the process for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE).
6. Validates TJC compliance with the Medical Staff chapter and assists with the development of Medical Staff organizational policies, Rules and Regulations, and Bylaws.
7. Assists the Graduate Medical Education program with accreditation survey preparation and validates ongoing compliance with ACGME and TJC standards.
8. Co-chairs the Clinical and Environmental Safety Committee and ensures that all TJC and other regulatory agency mandated safety reporting is presented and reviewed.
9. Submits written response to all Joint Commission and Office of Health Care Quality patient complaints within the required timeframes.

What You Need to Be Successful:

Three to five years of acute care quality and regulatory compliance experience.
We are an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

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