Addendum to the 2009 NAMSS Staffing Study Verbatim Comments In 2009, NAMSS commissioned a study to obtain benchmark data and establish key findings relevant to the medical staff services/credentialing field. Information was collected on the various domains and tasks executed by practitioners. Respondents were given the opportunity to specify the position/title, facility type, and the individual responsible for particular tasks. The findings in this addendum (six of six) of the report illustrate the individual verbatim responses for those individuals who selected Other for the respective question. Prepared By: Market Research & Statistics Group SmithBucklin Corporation September 2009
Table of Content Facility Information 2-4 Current Position or Title 2-3 Type of Facility/Organization 4 Performance Domains 5-47 Credentialing and Privileging 5-13 Primary Source Verification 13-17 Compliance 17-22 Operations 23-31 Physician Outreach 31-39 Human Resources 39-42 - 1 -
2. What is your current position or title? Other (154 responses) - Medical Staff Services Manager. (19 responses) - Manager, Medical Staff Services. (15 responses) - Manager Medical Staff Services. (4 responses) - Medical Staff Office Manager. (4 responses) - Administrative Assistant/Medical Staff Coordinator. (3 responses) - Administrative Assistant. (3 responses) - Medical Staff Coordinator. (3 responses) - Medical Staff Manager. (3 responses) - Medical Staff Services Supervisor. (3 responses) - Medical Staff Specialist. (3 responses) - Supervisor, Medical Staff Services. (3 responses) - Credentialing Supervisor. (2 responses) - Director of Operations. (2 responses) - Manager, Medical Staff Administration. (2 responses) - Vice President of Medical Staff Affairs. (2 responses) - Administrative Manager. - Administrative Secretary for the Medical Staff. - Administrative Assistant/Medical Staff Secretary. - Assistant Director. - Assistant Vice President, Professional Affairs. - Associate Director, Credentialing. - Assistant to the CEO/Medical Staff Coordinator. - Assistant Vice President Medical Administration. - Assistant to the CEO. - C&P Supervisor. - Chief Operating Officer. - Clinical Educator. - Consultant. - Coordinator Business Office/Credentialing. - Coordinator, Administration/Med Staff. - Coordinator, Medical Staff/Credentialing. - Credentialing and Contracts Manager. - Credentialing Database Coordinator. - Credentialing Director. - Credentialing Program Manager. - CVO Director. - Director Medical Staff Office. - Director of Compliance/Risk Management/Physician Services. - Director of Compliance/Risk/Physician Services. - Director of Credentialing and Enrollment. - Director of Medical Staff Relations and Recruitment. - Director of Provider Relations. - Director Physician Support Services. - Director Quality Management and Risk Management. - Director, Central Verification Office. - Director, Credentialing and Data Management. - Director, GSSA Central Verifications Unit. - Director, Medical Affairs. - Director, Medical Staff Administration. - Director, Medical Staff Services and House Staff Affairs. - Executive Secretary. - Executive/Medical Staff Secretary. - Health System Coordinator. - Insurance Enrollment Manager. - Lead Medical Staff Coordinator. - 2 -
2. What is your current position or title? Other (154 responses) continued - Manager, Medical Staff Administration. - Manager, Medical Administration. - Manager, Medical Affairs. - Manager, Medical Affairs/House Staff Support Services. - Manager, Medical Staff Affairs. - Manager, Physician Services. - Medical Staff CME Coordinator. - Medical Staff Credentialing Officer. - Medical Staff Operations Manager. - Medical Staff Resources Supervisor. - Medical Staff Services. - Medical Staff Services Secretary. - Medical Staff Support Services Administrator. - Medical Staff Services Manager. - Medical Support Services Manager. - Manager of MS Services. - MSO Supervisor. - Office Manager. - Peer Review Coordinator. - Performance Improvement/Quality Coordinator; CEO, CCO and DQRM Assistant; Governing Board for Facility Coordinator. - Physician Liaison. - Physician Recruiter. - Physician Services Director. - Physician Services Manager. - Program Assistant III. - Provider Relations Manager. - Quality and Medical Staff Coordinator. - Quality Improvement/Medical Staff Coordinator. - Quality Management Specialist. - Regional Manager of Medical Staff Administration. - Risk Manager/Compliance Officer. - Senior Credentialing Coordinator. - Senior Director, CVO and Credentialing. - Senior Medical Staff Coordinator. - Service Area Manager, Medical/Professional Staff Services. - Senior Medical Staff Specialist. - Supervisor of Credentialing. - System Director. - Team Leader Medical Staff Services. - Vice President of Nursing and Ancillary Services. - Vice President, CIO. - VPMA/CMO. - VPMSS/CMO. - 3 -
3. Which category best describes your facility? - Long-Term Acute Care Hospital (LTACH). (5 responses) - Critical Access Hospital. (9 responses) - Federal Hospital. (4 responses) - IPA. (2 responses) - Acadamic/Tert Trauma Center/Physician Practice. - Acute Hospital System. - Army Hospital. - Clinic, Acute Hospital and Long-term Care facility. - Clinical Staffing Resource. - Community Hospital. - Critical Access Hospital and two clinics. - Critical Care Hospital. - CVO, MSO and IPA. - Department of Veterans Affairs Hospital. - Government Hospital. - Healthcare Facility. - Healthcare System. - Hospital/CVO. - Independent Physicians Association (delegated group). - Inpatient/Outpatient/Long-term Care/Urgent Care/Home Based Primary Care/TeleMedicine. - Integrated Delivery System. - Integrated Hospital, Medical Group and Health Plan. - Management Services Organization. - Military. - Multi-facility System. - Multi-entity. - Multi-state Dialysis Clinics. - Physical Rehabilitation Hospital. - Physician Management Organization. - Preferred Provider Organization. - Primary and Specialty Care Hospital. - Regional Ambulatory Care Facility. - Specialty Practice. - State Veterans Home. - Surgery Center/Physician Practice/Managed Care. - Tribal Health System. - VA Hospital. - 4 -
Credentialing and Privileging: Applicant personal interview (178 responses) - Department Chair. (19 responses) - CEO. (14 responses) - Medical Director. (10 responses) - Service Chief. (8 responses) - Chief Medical Officer. (7 responses) - Human Resources. (7 responses) - Recruiter. (7 responses) - Chair. (6 responses) - Credential Chair. (6 responses) - Department Chief. (6 responses) - Physician Recruiter. (6 responses) - Administration. (5 responses) - Credentials Committee. (5 responses) - VPMA. (6 responses) - Chief of Staff. (4 responses) - Manager, Medical Staff Services. (4 responses) - Chief of Department. (3 responses) - Chief of Service. (3 responses) - Chairman of Committee/CEO. (2 responses) - Committee. (2 responses) - Credentialing Committee Member/Medical Director. (2 responses) - Medical Executive Committee. (2 responses) - Medical Staff Operations Manager. (2 responses) - Myself. (2 responses) - Physician Relations. (2 responses) - Physician. (2 responses) - Vice President of Clinic. (2 responses) - COO/Medical Director. - All MEC. - CEO and Department Chairs. - CEO or Chief. - CEO or Risk Manager. - CEO, Department Chair, MSS Director, and Credentialing Committee if applicable. - CEO, Physician Recruiter and/or Chair of Department. - Clinic Administration. - Clinical Department and Division Heads. - College of Medicine. - CVU. - Department Chair and the Advisory Committee. - Department Director. - Department Manager. - Deputy Command Surgeon. - Director of Operations. - Director of Unit. - Director Physician Support Services. - Executive Director. - Executives. - Hiring Chief. - Hospital Staff. - Manpower Committee. - Marketing. - 5 -
Credentialing and Privileging: - continued Applicant personal interview (178 responses) continued - Medical School Department. - Medical College Department Chair and Hospital CMO. - Medical Staff Leadership. - Medical Staff Specialist. - Physician Services Director. - President and CEO. - Professional Recruiter. - Provider Contracting Representative. - Regional Credentialing Committee. - Service Chief and/or Human Resources. - Service Line Director. - Service Line Management. - Supervisor. - Vice President. - VPMA or Vice President of Physicians Services. - VPMSS/Chief Medical Officer. - Applicant eligibility review. Analysis of applications/documents (95 responses) - Medical Staff Services Manager. (13 responses) - Human Resources. (11 responses) - CEO. (4 responses) - Chief of Staff. (4 responses) - Department Chair. (4 responses) - Manager. (3 responses) - Administrative Assistant. (2 responses) - Chair. (2 responses) - Chief Medical Officer. (2 responses) - Credentialing Committee MDs. (2 responses) - CVO. (2 responses) - Director. (2 responses) - Medical Director. (2 responses) - Medical Staff Services Supervisor. (2 responses) - Myself. (2 responses) - Recruiter. (2 responses) - VPMA. (2 responses) - Administrator. - Associate Department Director. - Both MSP's. - CEO and Department Chairs. - CEO or Credentials Committee. - Chief of Service. - College of Medicine. - Credentialing Coordinator and IRB Coordinator. - Credentialing Analyst or Credentialing Leader. - Credentialing Assistant. - Credentials Chair. - Department Chief. - Deputy Command Surgeon. - Director of Provider Relations. - 6 -
Credentialing and Privileging: - continued Analysis of applications/documents (95 responses) continued - Hospital Vice President. - Manpower Committee. - MDs. - MEC. - Medical Staff Assistant. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Operations Manager. - Medical Staff Specialist. - Part of analysis. - Physician Liaison. - Physician Recruiter. - Physician Services. Director. - Secretary. - Service Committee Chairs. - Service Line Management. - Senior Credentialing Analyst. - Senior VPMA. - Supervisor. Committee presentation for approval of appointments and credentialing (72 responses) - Manager, Medical Staff Services. (14 responses) - Credentials Chair. (3 responses) - Credentials Committee. (3 responses) - Myself. (3 responses) - Administrative Assistant. (2 responses) - Coordinator and Director. (2 responses) - Credentialing Supervisor. (2 responses) - Department Chairs. (2 responses) - Medical Staff Services Supervisor. (2 responses) - Manager. - Administrative Manager. - Administrator. - Assistant Director. - Assistant to CEO. - CEO. - Chairman. - Chief of Department. - Consultant. - Coordinator MS/Credentialing. - Credentialing Committee Chairman. - Credentialing Analyst. - Credentialing Analyst or Credentialing Leader. - Credentialing Coordinator also participates. - CVU. - Director of Provider Relations. - Director Physician Support Services. - Everyone on C&P Staff. - Hospital Staff. - Manager. - 7 -
Credentialing and Privileging: - continued Committee presentation for approval of appointments and credentialing (72 responses) continued - Manager and Coordinators. - Manager and Director. - Medical Staff Super and Specialists. - Medical Director. - Medical Executive Committee. - Medical Staff Committee. - Medical Staff Credentialing Officer. - Medical Staff Office Manager. - Medical Staff Operations Manager. - Medical Staff Services. - Medical Staff Specialist. - MSS Director, Credentialing Committee Primary Reviewer. - Physician Liaison. - Physicians and Medical Staff Credentialing. - Program Manager. - Service Area Manager, Medical/Professional Staff Services. - Supervisor. Reappointments and recredentialing including analysis of applications and documents (52 responses) - Medical Staff Services Manager. (8 responses) - Administrative Assistant. (3 responses) - All MSP Staff. (3 responses) - Medical Staff Assistant. (3 responses) - Myself. (3 responses) - Credentialing Specialist. (2 responses) - Medical Staff Services Staff. (2 responses) - Supervisor. (2 responses) - Manager. - Administrative Manager. - Assistant Director. - Assistant to CEO. - Centralized Credentialing Office and Medical Staff Coordinator. - Clinical Service Committee Chairs. - Consultant. - Coordinator MS/Credentialing. - Credentialing Assistant. - Credentialing Analyst. - Credentialing Analyst or Credentialing Leader. - Credentials Supervisor. - CS and staff. - CVO. - Hospital Staff. - Insurance Enrollment Manager. - Medical Staff Secretary. - Medical Staff Credentialing, Department Chair. - Physician Liaison. - Senior Credentialing Coordinator. - Specialist and Temporary Agency Help. - 8 -
Credentialing and Privileging: - continued Committee presentation for approval of reappointment and recredentialing (62 responses) - Senior Credentialing Consultant and Credentialing Administrator. - Supervisor, Medical Staff Services. - Vice President of Nursing. - Manager, Medical Staff Services. (11 responses) - Credentialing Committee Chairman. (3 responses) - Credentials Committee. (3 responses) - Myself. (3 responses) - Supervisor. (3 responses) - Administrative Assistant. (2 responses) - Credentialing Supervisor. (2 responses) - Manager. (2 responses) - Medical Staff Services Supervisor. (2 responses) - Administrative Manager. - All. - Assistant Director. - Assistant to CEO. - Both Manager and Coordinator. - CEO. - Chairmen. - Chief of Department. - Consultant. - Coordinator MS/Credentialing. - Coordinator and Director. - Credential Administrators and Credentialing Manager. - Credentialing Analyst. - Credentialing Analyst or Credentialing Leader. - Credentialing Specialist. - CVU. - Department Chair. - Everyone on C&P Staff. - Hospital Staff. - Manager and Coordinators. - Manager and Director. - Medical Staff Super and Specialists. - Medical Director. - Medical Staff Credentialing Officer. - Medical Staff Office Manager. - Medical Staff Secretary. - Medical Staff Services. - Medical Staff Specialist. - Part of overall assessment. - Physician Liaison. - Program Manager. - Professional Standards Board. - Senior Medical Staff Coordinator. - Temporary Agency Help. - 9 -
Credentialing and Privileging: - continued Processing requests for additional privileges (44 responses) - Manager, Medical Staff Services. (13 responses) - Administrative Assistant. (3 responses) - Myself. (3 responses) - Medical Staff Assistant. (2 responses) - Assistant Director. - Assistant to CEO. - Both Credentials Coordinator and MS Service Coordinator. - CME Coordinator. - Coordinator MS/Credentialing. - Credentials Supervisor. - CVO. - Department Chief. - Everyone on C&P Staff. - Manager. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Operations Manager. - Medical Staff Secretary. - Medical Staff Services. - Medical Staff Specialist. - Medical Staff Credentialing and staff. - Physician Liaison. - Senior Credential Consultant. - Supervisor. - Supervisor, Medical staff Services. - Vice President of Nursing. Focused professional practice evaluation/ongoing professional practice evaluation - Medical Staff Services Manager. (15 responses) - Quality Management. (13 responses) - Director of Quality Management. (12 responses) - Quality Department. (9 responses) - Performance Improvement. (5 responses) - Quality Improvement Department. (5 responses) - Manager. (4 responses) - Risk Manager. (4 responses) - Clinical Department. (3 responses) - Department Chair. (3 responses) - Myself. (3 responses) - Peer Review Coordinator. (3 responses) - Performance Improvement Department. (3 responses) - Quality Coordinator. (3 responses) - Administrative Assistant. (2 responses) - Credentialing Chair. (2 responses) - Medical Director. (2 responses) - Performance Improvement Coordinator. (2 responses) - Quality Improvement Analyst. (2 responses) - Quality Management. (2 responses) - Quality Analyst. (2 responses) - Quality Staff. (2 responses) - Being developed in collaboration with QM. - 10 -
Credentialing and Privileging: - continued Focused professional practice evaluation/ongoing professional practice evaluation continued - Both Medical Staff Services Director and Chief Medical Officer. - Both MSP's. - CEO. - Chairman. - Chair/QA Department. - Chief of Service. - Coordinator MS/Credentialing. - Coordinator and Clerk. - Credentialing data specialist. - CVO. - Deputy Command Surgeon. - Director of Quality/RM and VPMSS/CMO. - Director and Coordinators. - Director and others. - Director Physician Support Services. - Division Chief. - Group including Risk Manager, Medical Director, Medical Records Director, and Medical Staff Coordinator. - Hospital Staff. - MEC. - Medical Executive Committee. - Medical Staff Credentialing Officer. - Medical Staff Office Manager. - Medical Staff Operations Manager. - Medical Staff Services. - Medical Staff Services Supervisor. - Mostly quality provides to us. - MS QA Specialist. - Medical Staff Credentialing, Medical Staff Services Director, Section Chiefs, and Department Chair. - Medical Staff Services, HIM, IS - Joint Efforts. - Outcomes Management. - Peer Review Assistant. - Peer Review. - Peer Review Nurse. - Physician Liaison. - Physician Chair of each department. - Performance Improvement Analyst. - Performance Improvement Director. - Performance Improvement Specialist. - Performance Improvement Staff. - Program managers. - Privileging Administrator. - Quality Assurance Analyst. - Quality Assurance Committee. - Quality Assurance Manager. - Quality Improvement Director. - Quality Improvement, Social Services, VP of Medical Affairs. - Quality Management Coordinator. - Quality Management Director. - Quality Management Senior Project Coordinator, QM Nurse or Director. - 11 -
Credentialing and Privileging: - continued Focused professional practice evaluation/ongoing professional practice evaluation continued - QMRC Director. - Quality Department coordinates- MSO maintains file. - Quality and Medical Staff Office. - Quality Assurance Department. - Quality Chief. - Quality Department and Medical Affairs Director. - Quality Officer. - Quality Person and Manager. - Quality Resource Management Personnel. - Quality Review. - Quality/Medical Records. - Quality/Risk. - Registered Nurse. - Section/Service Chiefs. - Senior Decision Support Specialist. - Service. - Service Area Manager, Medical/Professional Staff Services. - Service Chief. - Service Line Director. - Service Line Management. - Shared between Quality Asst and Medical Staff Coordinator. - Supervisor. - Vice President of Nursing/UR. - Vice President Quality Management. - VPMA. Investigation of issues/data analysis (112 responses) - Manager, Medical Staff Services. (17 responses) - Quality Department. (8 responses) - Administrative Assistant. (4 responses) - Director of Quality Management. (4 responses) - Credentialing Supervisor. (3 responses) - Medical Staff Services Supervisor. (3 responses) - Myself. (3 responses) - Quality Management Manager. (3 responses) - Risk Management. (3 responses) - All. (2 responses) - Manager. (2 responses) - Peer Review Coordinator. (2 responses) - VPMA. (2 responses) - Assistant Chief of Staff. - Both medical Staff Services Director and Chief Medical Officer. - Chief Medical Officer and Chief of Staff. - Consultant. - Coordinator MS/Credentialing. - Credentialing Coordinator and IRB Coordinator. - Credentialing Specialist and Director. - Credentialing Analyst. - Credentialing Analyst, Credentialing Leader or Director. - Credentials Specialist and Manager, Medical Staff Services. - CVO. - 12 -
Credentialing and Privileging: - continued Investigation of issues/data analysis (112 responses) continued - Data Analyst. - Department Chief. - Director of Quality/RM and VPMSS/CMO. - Director and Supervisor. - Director and Coordinator. - Director of Provider Relations. - Director Physician Support Services. - DQRM. - Everyone on C&P Staff. - Group. - HIM and Quality Coordinator. - Insurance Enrollment Manager. - MEC. - Medical Staff Assistant. - Medical Staff Super and Specialists. - Medical Affairs Coordinator. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Office Manager. - Medical Staff Operations Manager. - Medical Staff Services. - Medical Staff Services Coordinator. - Medical Staff Services Director, Section Chief, Department Chair, PRC Chair and COS. - Medical Staff Services and Risk Manager. - Peer Review Committee. - Performance Improvement Team. - Physician Liaison. - Performance Improvement Coordinator. - Performance Improvement Department. - Program Managers. - Quality Improvement, Vice President of Medical Affairs, Social Services and Safety. - Quality Management Coordinator/VPMA. - Quality Chief. - Quality/Risk. - Section/Service Chiefs. - Service Area Manager, Medical/Professional Staff Services. - Service Line Management. - Supervisor - Supervisor, Quality Assurance. - Troubleshooting. - VPMA. - Vice President of Medical Management. - Vice President Quality Management. - VPMA and MS Leadership. - 13 -
Primary Source Verification: Pre-application Evaluation (68 responses) - CVO. (8 responses) - Manager, Medical Staff Services. (7 responses) - Human Resources.(4 responses) - Department Chairman. (3 responses) - No pre-applications. (3 responses) - Administration. (2 responses) - Chief Medical Officer. (2 responses) - Chief of Service. (2 responses) - Myself. (2 responses) - Physician Recruitment. (2 responses) (2 responses) - Both MSP's. - Centralized Credentialing Office and Medical Staff Coordinator. - CEO. - CEO/MDs. - CEO/Risk Manager. - Chief of Staff. - Clinic Administration. - Consultant. - Coordinator MS/Credentialing. - Coordinator/Specialists. - COS/COPS. - Director of Provider Relations. - Hospital Vice President. - Manager. - Manpower Committee. - MEC Committee. - Medical Staff Assistant. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Operations Manager, Medical Staff Operations Manager. - Network Management. - Physician Services Director. - Program Managers. - Provider Development. - Provider Relations. - Recruiting Specialist. - Recruitment. - Senior Credentialing Coordinator. - Service. - Senior Credentialing Analyst. - Staff model. Obtaining and Evaluating Information (63 responses) - CVO. (13 responses) - Manager, Medical Staff Services. (11 responses) - Myself. (3 responses) - Administrative Assistant. (2 responses) - Medical Staff Services Assistant. (2 responses) - Administration Manager. - Assistant to CEO. - Both MSP and Assistant. - 14 -
Primary Source Verification: - continued Obtaining and Evaluating Information (63 responses) continued - Both MSP's. - Centralized Credentialing Office and Medical Staff Coordinator. - Centrally performed. - Chairman. - Chief of Staff Office. - Coordinator MS/Credentialing. - Coordinator/Specialists. - Credentialing Coordinator and IRB Coordinator. - Credentialing Analyst. - Credentialing Analyst and Credentialing Leader. - Credentials Supervisor. - CVO, Administrative Assistant. - Director and Assistant. - Manager. - MEC Committee. - Medical Staff Quality Specialist. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Operations Manager. - Medical Staff Services. - Medical Staff Specialist. - Medical Staff Services Coordinator as well. - Recruiting Specialist. - Regional Credentialing Office. - Section/Service Chief. - Senior Credentialing Coordinator. - Specialist and Temp. - Senior Credentialing Consultant and Credentialing Administrators. Verification and Documentation (66 responses) - CVO. (21 responses) - Manager, Medical Staff Services. (10 responses) - Myself. (3 responses) - Administrative Assistant. (2 responses) - Medical Staff Assistant. (2 responses) - Administration Manager. - Assistant to CEO. - Both MSP and Assistant. - Both MSP's. - Centralized Credentialing Office and Medical Staff Coordinator. - Centrally performed. - Contracted CVO. - Coordinator/Specialists. - Credentialing Coordinator and IRB Coordinator. - Credentialing Analyst. - Credentialing Analyst or Credentialing Leader. - Credentialing Specialist. - Credentials Supervisor. - Director and Assistant. - 15 -
Primary Source Verification: - continued Verification and Documentation (66 responses) continued - Insurance Enrollment Manager. - Manager. - Medical Staff Quality Specialist. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Operations Manager. - Medical Staff Services. - Medical Staff Specialist. - Medical Staff Services Coordinator as well. - Senior Credentialing Coordinator. - Specialist and Temp. - Senior Credentialing Consultant and Credentialing Administrators. - UIHC. Investigating and Validating Discrepancies and Information (69 responses) - Manager, Medical Staff Services. (11 responses) - CVO. (8 responses) - Credentialing Supervisor. (3 responses) - Myself. (3 responses) - Administrative Assistant. (2 responses) - Manager. (2 responses) - Medical Staff Assistant. (2 responses) - MSS Coordinator. (2 responses) - Supervisor. (2 responses) - All MSP's. - All, time varies. - Assistant to CEO. - Central Verification. - Centralized Credentialing Office and Medical Staff Coordinator. - Coordinator/Specialists. - Coordinator and Director. - Credentialing Coordinator and IRB Coordinator. - Credentialing Coordinator and MS Service Coordinator. - Credentialing Analyst. - Credentialing Leader. - Credentialing Specialist. - Credentialing Specialist and Manager, Medical Staff Services. - CVO, Administrative Assistant. - Director and Assistant. - Director of Provider Relations. - Director Physician Support Services. - Director, CVO. - Insurance Enrollment Manager. - Medical Staff Quality Specialist. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Operations Manager. - Medical Staff Services. - Medical Staff Specialist. - Office Manager. - Outsourced to CVO. - 16 -
Primary Source Verification: - continued Investigating and Validating Discrepancies and Information (69 responses) continued - Plus Director. - Recruiting Assistant. - Senior Credentialing Coordinator. - Specialist and Temp. - Senior Credentialing Consultant and Credentialing Administrators with manager support as needed. - UIHC. Responding to Inquiries From Other Healthcare Organizations (57 responses) - Manager, Medical Staff Services. (8 responses) - Medical Staff Assistant. (6 responses) - Administrative Assistant. (4 responses) - Myself. (3 responses) - All MSP's. (2 responses) - Credentialing Assistant. (2 responses0 - CVO. (2 responses) - PHDB. (2 responses) - Administrative Secretary. - Assistant to CEO. - Both Med Staff Services Director/Credentialing Specialist. - Coordinator MS/Credentialing. - Coordinator/Specialists. - Credentialing Coordinator and IRB Coordinator. - Credential Administrator. - Credentialing Data Specialist. - Director of Credentialing. - Director Physician Support Services. - Inquiry Coordinator. - Insurance Enrollment Manager. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Operations Manager. - Medical Staff Secretary. - Medical Staff Services. - Medical Staff Service Coordinator and Clerical Staff. - Online. - Outsource HPDB. - Physician Services Manager. - PT person help. - QM Staff. - Temporary Agency Help. - Verifications are available online. - Volunteer. - Vice President of Nursing. - 17 -
Compliance: Bylaws, rules, regulations, policies and procedures (93 responses) - Manager, Medical Staff Services. (25 responses) - CEO. (3 responses) - Manager. (3 responses) - Medical Staff Services Supervisor. (3 responses) - Myself. (3 responses) - Supervisor. (3 responses) - Administrative Assistant. (2 responses) - Credentialing Supervisor. (2 responses) - Medical Director. (2 responses) - Medical Staff Services. (2 responses) - Medical Staff Services Coordinator/QM Manager. (2 responses) - VPMA. (2 responses) - All staff. - Bylaws Chairman. - Assistant to Senior VPMA. - AVP Medical Administration. - Bylaws Committee. - Chief of Staff. - CME Coordinator. - Committee. - Compliance Manager. - Consultant. - Coordinator MS/Credentialing. - Coordinator and Assistant. - Credentialing Director. - Credentialing Strategy Manager. - Director of Quality/RM. - Director of Provider Relations. - Director Physician Support Services. - Director, Manager and Lead Coordinator. - Executive Director. - Health Systems Specialist. - Manager and Director - Manager of Medical Affairs/House staff Support Services. - Medical Staff Coordinator and CIO. - Medical Staff Organization. - Medical/Legal Chief. - Medical Staff Credentialing Officer. - Medical staff, CEO. - Medical Service Assistant. - Office Manager. - Physician Services Manager. - QI, Vice President of Medical Affairs. - Quality Control/Human Resources. - Quality Management Department. - Service Area Manager, Medical/Professional Staff Services. - Senior Medical Staff Coordinator. - Supervisor of Credentialing. - Updated annually. - Various, culminating with Administrative Assistant. - 18 -
Compliance: - continued Bylaws, rules, regulations, policies and procedures (93 responses) continued - Vice President of Regulations. - Vice President Quality/Risk. Preparing for accreditation reviews and ongoing compliance with regulatory standard (89 responses) - Manager, Medical Staff Services. (24 responses) - Director of Quality/RM. (4 responses) - All staff. (3 responses) - Manager. (3 responses) - Myself. (3 responses) - Supervisor. (3 responses) - Health Systems Specialist. (2 responses) - Medical Director. (2 responses) - Medical Staff Services. (2 responses) - Medical Staff Services Supervisor. (2 responses) - Quality Department. (2 responses) - Supervisor of Credentialing. (2 responses) - VPMA. (2 responses) - Administration Manager. - Administrative Assistant. - Compliance Department. - Compliance Manager. - Consultant. - Coordinator MS/Credentialing. - Credentialing Director. - Director Performance Improvement. - Director Physician Support Services. - Director, CVO. - DON. - Manager and all staff. - Manager of Medical Affairs/Housestaff Support Services. - Manager, Coordinator and Clerical. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Services Assistant. - Medical Staff Services Coordinator, Risk Manager, Performance Improvement Director. - NCQA Project Manager. - Office Manager. - Performance Improvement Department. - Physician Services Manager. - Quality Assurance Manager/MSP. - Quality Improvement, Vice President of Medical Affairs and Safety. - Quality Management Staff. - Quality Administrator. - Quality Control/Human Resources. - Quality Manager. - Quality Officer. - Quality Specialist. - Service Area Manager, Medical/Professional Staff Services. - Several staff. - Senior Medical Staff Coordinator. - Vice President of Clinic. - Vice President Quality/Risk. - 19 -
Compliance: - continued Internal audits (files) (74 responses) - Manager, Medical Staff Services. (14 responses) - All Staff. (4 responses) - Myself. (3 responses) - Supervisor, Medical Staff Services. (3 responses) - Administrative Assistant. (2 responses) - Credentialing Coordinator. (2 responses) - Quality Assurance. (2 responses) - Quality Assurance Manager. (2 responses) - Volunteer Staff. (2 responses) - VPMA. (2 responses) - Auditing Department. - Compliance Manager. - Consultant. - Credentialing Director. - Credentialing Specialist and Manager, Medical Staff Services. - Credentialing Supervisor. - CVO. - Department Chair. - Director of Provider Relations. - Director of Quality Management. - Director, CVO. - Division Director. - DON. - Handle by everyone. - HSS. - Insurance Enrollment Manager. - Manager and all staff. - Medical staff Supervisor and Specialist. - Medical Director. - Medical Staff Assistant. - MSP and Assistant. - Medical Staff Services Coordinator as well. - Office Manager. - Performance Improvement Team. - Physician Services Manager. - Quality Administrator. - Quality Control/HR. - Quality Improvement. - Senior Credentialing Staff and Credentialing Leader. - Senior Medical Staff Coordinator. - Supervisor. - Supervisor of Credentialing. - Supervisor, Quality Assurance. - Team. - UR Nurses. - Utilization Review. - Vice President of Medical Affairs, Quality Improvement, Social Services, Safety. - 20 -
Compliance: - continued Audits for delegations (42 responses) - Manager, Medical Staff Services. (5 responses) - All staff. (2 responses) - Self. (2 responses) - Administration Team. - Auditing Department. - CEO. - Consultant. - Credentialing Assistant. - Credentialing Director. - Credentialing Leader. - Credentialing Supervisor. - CVO. - Delegation Coordinator. - Delegation Specialist. - Director of Provider Relations. - Director Q&A. - Division Director. - DON. - HSS. - Managed Care Office. - Medical Staff Super and Specialist. - Medical Director. - Myself - Administrative Assistant. - Office Manager. - Performance Improvement Team. - Physician Services Manager. - Quality Assurance. - Quality Management Staff. - Quality Control/Human Resources. - Quality Manager. - Region. - Safety Director, Quality Improvement. - Supervisor of Credentialing. - Supervisor, Operations. - UR Nurses. - VPMA. Sanctions, complaints, adverse data and NPDB (66 responses) - Manager, Medical Staff Services. (13 responses) - VPMA. (4 responses) - CVO. (3 responses) - Myself. (3 responses) - Risk Manager. (3 responses) - Administrative Assistant. (2 responses) - All. (2 responses) - Medical Staff Assistant. (2 responses) - Supervisor of Credentialing. (2 responses) - Centralized Credentialing Office and MSC. - CME Coordinator and Credentialing Coordinator. - Coordinator MS/Credentialing. - Coordinator/Specialists. - 21 -
Compliance: - continued Sanctions, complaints, adverse data and NPDB (66 responses) continued - COPS/COS. - Credential Administrators. - Credentialing Analyst. - Credentialing Business Associates, Credentialing Analysts or Credentialing Leader. - Credentialing Staff and Medical Staff Services Supervisor. - Director of Provider Relations. - Director Physician Support Services. - Director, two specialists. - Executive/Medical Staff Secretary. - Manager and Coordinator. - Medical Director. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Operations Manager. - Medical Staff Services. - Medical Staff Services Director. - Medical Staff Services Supervisor. - Medical Staff Services Director and clerical staff jointly. - MSSC, Risk Manager and CEO. - Physician Services Manager. - Quality Control/Human Resources. - Recruiting Assistant. - Senior Credentialing Coordinator. - Service Area Manager, Medical/Professional Staff Services. - Several staff. - Senior Medical Staff Coordinator. - Supervisor. - Vice President of Nursing/CEO. Physician/Organizational site reviews (57 responses) - Manager, Medical Staff Services. (6 responses) - Quality Management. (5 responses) - Medical Director. (3 responses) - VPMA. (3 responses) - CVO. (2 responses) - Director. - Director of Provider Relations. - Director Physician Support Services. - Director Q&A. - Division Director. - JC Coordinator, Risk Management Director. - Managed Care Credentialing Office. - Manager. - Me. - MSS and Credentialing Coordinator also involved. - Peer Review. - Physician Recruiter and VPMSS/CMO. - Practice Chief. - Practice Manager. - Program Managers. - 22 -
Operations: Physician/Organizational site reviews (57 responses) continued - Provider Relations Manager (RN). - Provider Services Representatives. - Quality Improvement Director. - Quality Nurses. - Quality Management Nurse, Vendor, and Credentialing Analyst. - Quality Control/Human Resources. - Quality Improvement. - Quality Officer. - Region. - Risk/Quality Assurance Manager. - Service Area Manager, Medical/Professional Staff Services. Correspondence to practitioners, delegated entities and others (87 responses) - Manager, Medical Staff Services. (19 responses) - All staff. (11 responses) - Medical Staff Assistant. (5 responses) - Administrative Assistant. (3 responses) - All Medical Service Staff. (3 responses) - Director and Coordinator. (3 responses) - Coordinator/Specialists. (2 responses) - Manager. (2 responses) - Medical Staff Services Staff. (2 responses) - Myself. (2 responses) - Supervisor of Credentialing. (2 responses) - UM/QI Manager. - Vice President of Medical Affairs, Safety, Quality Improvement, Social Services. - Administration Manager. - Director. - Assistant Director. - AVP. - Both MSP's. - CEO/MDs/Asst to CEO. - Consultant. - Coordinator MS/Credentialing. - Credentialing Analyst. - Credentialing Analyst and Credentialing Leader. - Director and Assistant. - Director's Office. - Information Analyst. - Inquiry Coordinator. - Insurance Enrollment Manager. - Medical Affairs Coordinator. - Medical Staff Services Supervisor. - Manager/Specialist. - Medical Staff Services Director, MSC. - Office Manager. - Physician Recruiter/Retention; VPMSS/CMO. - Physician Services Manager. - Senior Credentialing Coordinator. - 23 -
Operations: - continued Correspondence to practitioners, delegated entities and others (87 responses) - Several. - Senior Medical Staff Coordinator. - Senior Credentialing Consultants and Credentialing Administrators. - Supervisor. - Three employees share. - Varies. - Vice President of Medical Affairs, Quality Improvement, Safety, Social Services. - VPMA. Meeting Logistics, documentation and follow-up (92 responses) - Manager, Medical Staff Services. (15 responses) - All staff. (6 responses) - Administrative Assistant. (5 responses) - All MSP in office. (4 responses) - Medical Staff Assistant. (4 responses) - Myself. (3 responses) - Three employees share. (3 responses) - Director. (2 responses) - Director and Coordinators. (2 responses) - Medical Staff Services. (2 responses) - Administrative Manager. - All staff including Director, Credentials Coordinators and clerical staff - Assistant Director. - Assistant to Sr. VP of Medical Affairs. - Assistant to CEO. - Both the Medical Staff Services Manager and Credentialing Coordinator. - CME Coordinator. - Consultant. - Coordinator and Specialist. - Coordinator MS/Credentialing. - Credentialing Business Associate. - Credentialing Director. - Credentialing Supervisor. - Director. - Director and Assistant. - Director and Manager. - Director of Provider Relations. - DON. - Emergency Management Program. - Human Resources. - Insurance Enrollment Manager. - Manager, Medical Staff Services and Credentialing Specialist. - Many departments. - Medical Staff Super and Specialist. - Medical Staff Assistant, Medical Staff Coordinator. - Medical Staff Credentialing Officer. - Medical Staff Specialist. - Meeting Management Coordinator. - Meeting Specialist. - Medical Staff Services Director and staff - 24 -
Operations: - continued Meeting Logistics, documentation and follow-up (92 responses) continued - Medical Staff Services Director, MSC, Chairpersons. - Operations Manager. - Quality Management Manager. - Secretary. - Senior Credentialing Coordinator. - Service Area Manager, Medical/Professional Staff Services. - Senior Medical Staff Coordinator. - Supervisor. - Supervisor of Credentialing. - Supervisor, Medical Staff Services. - Three: Director, Coordinator and Credentialing Specialist. - UM/QI Manager. - Vice President of Nursing. Database Updates (88 responses) - Manager, Medical Staff Services. (10 responses) - All staff. (6 responses) - Medical Staff Assistant. (5 responses) - Administrative Assistant. (4 responses) - Data Analyst. (4 responses) - All MSS Staff. (3 responses) - CVO. (3 responses) - IS Department. (3 responses) - Director. (2 responses) - Myself. (2 responses) - Assistant to CEO. - AVP. - Both MSP's. - Both the Medical Staff Services Manager and Credentialing Coordinator. - Business Systems Analyst. - Clerical Staff. - Consultant. - Coordinator MS/Credentialing. - Coordinator/Specialists. - Coordinator and Clerk. - Coordinator and Manager. - Credentialing and Director both. - Credentialing Assistant. - Credentialing Data Analyst. - Credentials Supervisor. - Credentialing Specialist and Coordinator. - Database Specialist. - Director and Coordinator. - Information Analyst. - Information Services. - Information Resource Management. - Insurance Enrollment Manager. - Managed Care Analyst. - Manager, Medical Staff Services and Credentialing Specialist. - 25 -
Operations: - continued Database Updates (88 responses) continued - Manager/Specialist. - Medical Staff Personnel. - Medical Staff Credentialing Officer and Credentialing Specialist. - Medical Staff Services. - Medical Staff Specialist. - Medical Staff Personnel and Assistant. - Multiple. - Operations Specialist. - Recruiting Assistant. - Senior Credentialing Coordinator. - Specialist, Manager. - Senior Medical Staff Coordinator. - Senior Credentialing Cons and Credentialing Administrators. - System Analyst. - Systems specialist. - Team. - Technology. - Varies. - Volunteers. - Vice President of Nursing. Financial Management (i.e., dues, fees, budgeting) (83 responses) - Manager, Medical Staff Services. (21 responses) - Medical Staff Assistant. (4 responses) - Medical Staff Services Supervisor. (4 responses) - Administrative Assistant. (2 responses) - All staff. (2 responses) - CEO. (2 responses) - CFO. (2 responses) - Credentialing Supervisor. (2 responses) (2 responses) - Financial Services. (2 responses) - Myself. (2 responses) - VPMA. (2 responses) - Accountant. - Accounts Manager. - Administrator. - Assistant to CEO. - CEO/CFO. - Clerical and Director. - CME Coordinator. - Coordinator MS/Credentialing. - Coordinator and Clerk. - Coordinator and Director. - Credential Chair. - Credentialing Director. - Director and Managers. - Director of Quality Management. - Director Physician Support Services. - Executive Director. - 26 -
Operations: - continued Financial Management (i.e. dues, fees, budgeting) (83 responses) continued - Fiscal Services. - IRB Coordinator. - Manager. - Medical Staff Services Director. - Medical Board Secretary. - Medical Staff Services. - Office Manager. - Physician Liaison. - Physician Services Manager. - Quality Improvement. - Risk Manager. - Senior Credentialing Coordinator. - Senior Director. - Service Area Manager, Medical/Professional Staff Services. - Shared Director/Specialist. - Senior Medical Staff Coordinator. - Supervisor. - Supervisor of Credentialing. - Team. Call Scheduling (61 responses) - Manager, Medical Staff Services. (8 responses) - Administrative Assistant. (2 responses) - Clinical Department Staff. (2 responses) - Medical Staff Assistant. (2 responses) - Medical Staff Specialist. (2 responses) - Myself. (2 responses) (2 responses) - Service Secretaries. (2 responses) - Supervisor. (2 responses) - By service. - CEO. - Chairmen. - Chief of Staff. - Clerical Staff. - Clinical Division Managers. - CME Coordinator. - CMO. - Credential Chair. - Credentialing Specialist. - Credentialing Supervisor. - Department Chairs and ER Registered Nurse. - Director of Operations. - Emergency Department. - For Locums not staff physicians. - Hospital CEO. - IRB Coordinator and Credentialing Coordinator. - Manager. - MDs/Assistant to CEO. - 27 -
Operations: - continued Call Scheduling (61 responses) continued - Medical Director. - Medical Staff. - Nursing Director. - Nursing Secretary. - Oversight of process only Director. - Physician Recruiter/Retention. - Physician Staff. - Registration. - Responsibility of Medical College Clinical Departments. - Scheduling Coordinator. - Section Chiefs. - Service Line. - Service Line Directors. - Site Manager. - Standards Officer. - VPMA. - Vice President-Patient Care Services. Conflict Resolution (106 responses) - Manager, Medical Staff Services. (16 responses) - VPMA. (11 responses) - Chief Medical Officer. (5 responses) - Medical Director. (5 responses) - Human Resources. (4 responses) - Chief of Staff. (3 responses) - CMO. (3 responses) - Myself. (3 responses) - All Staff. (2 responses) - Chief of Service. (2 responses) - Director and Coordinator. (2 responses) - Manager. (2 responses) - Medical Executive Committee. (2 responses) - Supervisor, Medical Staff Services. (2 responses) - Administration, Management, and MSC. - Administration. - Administrator. - Administrator or Medical Director. - Administrator, CMO, Chief of Staff. - Assistant Director. - CEO. - CEO/CCO/Medical Director/Director of Quality. - CEO/Risk Manager. - CEO's Administrative Assistant. - Chairmen. - Clinic Practice Committee - CMO and ACMO. - Consultant. - Coordinator MS/Credentialing. - Credentialing Chair. - Credentialing Director. - Credentialing Manager and Credentialing Coordinator. - 28 -
Operations: - continued Conflict Resolution (106 responses) continued - Credentialing Supervisor. - Department Chairperson. - Director, two specialists. - EEO Coordinator. - Executive Director. - MD and ARNP. - Manager and Director. - Medical Staff Services Director, MSC, Medical Staff Leadership. - Multiple. - Physician Services Manager. - Performance Improvement Coordinator. - President and CEO. - Quality Manager. - Quality Officer. - Senior Medical Staff Coordinator. - Standard Officer. - Various as appropriate. - Vice President. - Vice President of Medical Affairs, Human Resources. - Vice President Quality/Risk. - Vice President-CMO. - VPMA and Coordinator. - VPMA/Outcomes Management. - VPMSS/CMO. Institutional review board (66 responses) - Manager, Medical Staff Services. (3 responses) - Risk management. (3 responses) - Another department. (2 responses) - CEO. (2 responses) - Director of Quality Management. (2 responses) - IRB Committee. (2 responses) - IRB Coordinator. (2 responses) - Medical Director. (2 responses) - Outsourced. (2 responses) - Quality Management. (2 responses) - Research Department. (2 responses) - VPMA. (2 responses) - Administration. - Administrator. - Administrator and Medical Director. - Administrative Secretary. - Board of Directors. - CEO/Risk Manager. - Chief of Staff. - CMO. - Command Surgeon. - Compliance Officer. - Corporate IRB. - 29 -
Operations: - continued Institutional review board (66 responses) continued - Credentialing Committee, Medical Staff, and Board of Trustees. - Credentialing Chair. - Delivery System. - Director Physician Support Services. - Director Q&A. - Education Director. - Executive Vice President/COO. - GME Coordinator - GME Director. - Hospital Operations Administration. - HRRC. - IRB Manager. - Me. - Medical Staff Assistant. - Medicine Chief/Sec. - Not in medical staff office. - Nurse Researcher. - Physician Services. - Physician Staff. - Quality Department. - Regional IRB. - Senior Research Nurse. - Supervisor, Medical Staff Services - Various Committees. - Vice President. - Vice President of Medical Management. - Vice President of Medical Affairs, CEO. - VPMSS/CMO. Physician Wellness (65 responses) - Manager, Medical Staff Services. (10 responses) - Chief Medical Officer. (4 responses) - VPMA. (4 responses) - Chair. (3 responses) - Medical Director. (3 responses) - CEO. (2 responses) - Medical Staff Services Supervisor. (2 responses) - Self. (2 responses) - Assistant Director - CEO/Risk Manager - Chair of Well-Being. - Chief Medical Officer, Director and Coordinator. - Chief Medical Officer's Executive Assistant. - Chief of Staff. - CMO and ACMO. - Committee Chairman. - Credentialing Chair. - Director of Medical Affairs. - Education Department. - Employee Health Nurse. - Health Systems Specialist. - 30 -
Operations: - continued Physician Wellness (65 responses) continued - Joint Medical College and Hospital initiatives. - Manager. - MDs. - Medical Affairs Coordinator. - Medical Executive Committee. - Medical Staff Operations Manager. - Medical Staff Services Director, Wellness Committee. - Not in medical staff office. - Physician Partners. - Physician Services Manager. - Physician Wellness Committee. - Quality Improvement Director. - Quality Officer. - Risk Manager. - Service Line and Human Resources. - Standards Officer. - Vice President. - Vice President Quality/Risk - VPMSS/CMO. - Wellness Committee. - Wellness Coordinator. Physician Outreach: Physician Recruitment (183 responses) - Physician Recruiter. (36 responses) - CEO. (13 responses) - Human Resources. (12 responses) - Physician Liaisons. (7 responses) - Physician Relations. (7 responses) - Manager, Medical Staff Services. (6 responses) - Administration. (4 responses) - Medical Director. (4 responses) - Recruiting Office. (4 responses) - Administrator. (3 responses) - Business Development. (3 responses) - Marketing. (3 responses) - Physician Services. (3 responses) - VPMA. (3 responses) - Director of Physician Relations. (2 responses) - Human Resources Director. (2 responses) - Network Management. (2 responses) - Outsourced. (2 responses) - President/CEO. (2 responses) - Professional Relations. (2 responses) - Recruiting Specialist. (2 responses) - Recruitment Coordinator. (2 responses) - Vice President of Medical Affairs. (2 responses) - ACEO. - 31 -
Physician Outreach: - continued Physician Recruitment (183 responses) continued - Administration, Division Recruiter. - Administrator, Director of Physician Services. - Another Department. - CEO and Board of Directors. - CEO, Regional Marketing Personnel, and Medical Leadership - CEO/MDs/Marketing. - CFO. - Clerical Departments. - Clinic Administration. - Clinical Department and Division Heads. - CMO. - Contracted. - Corporate Physician Recruiter. - Corporate Office. - Corporate Recruiter. - Credentialing Chair. - Department Chair. - Director of Operations. - Director. - Director, but COO responsible. - Director of Administration. - Director Physician Support Services. - Division Chief. - Employer. - Executives. - Health Recruiter. - Human Resources Officer. - Human Resources and Physicians. - Human Resources/Section Chiefs. - IRB Coordinator. - Matrixed Organization Coordinator. - MD group. - Medical Officer and CEO. - Medical Staff Services. - Medical Staff Services Supervisor. - Myself. - Physician Partner. - Physician Practice Director. - Physician Recruiter and VPMSS/CMO. - Physician Services Coordinator. - Physician Services Director. - Physician Services Department. - Program Managers. - Provider Services Representative. - Public Relations. - Recruitment by Medical College Department Chairs. - Recruitment/Retention Committee. - Regional Office. - School Administration. - Senior Management. - Service Chiefs. - 32 -