Medical Staff and CME Coordinator

Department: Quality, Medical Staff and Compliance
Report to: Medical Staff Manager
Type: Full-time
Requisition #12125

The Medical Staff & CME Coordinator assists in the coordination of medical staff affairs and performance improvement activities, in compliance with Joint Commission’s standards.

• Abstraction of data for department peer review activities.
• Prepare and gather department data for various PI projects including but not limited to Medical Staff Office as assigned.
• Support and assist in the planning of educational programs in adherence with CME regulations. This includes responsibilities of coordinating educational programs with faculty speakers, preparing evaluation forms, assisting the CME program assessments, and renewal of reaccreditation.
• Support and assist in the processing of Medical Staff initial and reappointment applications, credentialing activities including collection of required medical staff information (including but not limited to, COVID vaccinations, booster vaccination, annual flu vaccination, etc), and annual dues collection.
• Assist in the preparation for external surveys including but not limited to TJC surveys, GACH surveys, etc.
• Administrative responsibilities including but not limited to scheduling meetings and transcribing meeting minutes.
• Support and assist in Medical Staff Office & Performance Improvement activities.
• Support established teams/task forces, including prepare draft meeting agendas, take meeting minutes, and draft follow-up correspondences.
• Support the departments/sections, draft follow-up correspondences related to peer review/PI activities.
• Photocopying meeting packets for various Medical Staff committee/team meetings.
• Provide administrative support to the department including taking meeting minutes, scheduling meetings, filing, etc.
• Accepts and performs other duties as assigned.

• High school diploma or equivalent education/experience is required. Associate’s Degree or above is preferred.
• At least 2 years of experience in medical staff services at hospital setting.
• Knowledge of current regulatory requirements including but not limited to standards of the Joint Commission, the CMS Hospital Conditions for Participation, and Title 22 licensing requirements is preferred.
• Knowledge of physician credentialing and privileging procedures and standards.
• Excellent verbal and written communication skills.
• Proficient with Microsoft Office Word and Excel.
• Must possess excellent written/grammatical and oral communication skills.
• Highly organized, resourceful, motivated self-starter with excellent follow-through.
• Able to follow instruction identify discrepancies, and resolve problems.
• Ability to interrelate with and gain respect of physicians, nurses and other hospital personnel.
• Database management skills including querying, reporting, and document generation.

While performing the duties of this job, staff is regularly required to sit, stand, walk, talk and/or listen. He/she uses his/her hands to do computer work, write reports, do equipment set-up/cleaning/storage, clerical support, etc. He/she will be using the phone frequently. Good vision is needed to be able to read schedules, enter accurate data, etc. He/she must have good general health and demonstrate emotional stability so as to carry out the above-enumerated duties.

• Able to lift up to 30 pounds
• Use proper body mechanics when handling equipment
• Standing, walking and moving 50% of the day

Complies with Chinese Hospital Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.