Position Objective:

The Medical Staff Specialist reports to the Manager of Medical Staff Quality. This position is primarily responsible for managing the department’s credentialing software database and coordinating departmental projects and medical staff quality reporting. This position will lead OPPE/FPPE and maintain peer review data for medical staff member credentialing and professional practice evaluation, as well as provide support for Peer Review committees. This position will assist the Medical Staff Office, Medical Staff Leadership, and the Hospital System through analyzing database workflows and collecting and summarizing data to support project needs. This position also includes managing the expirables process for ensuring that all practitioners are current with their required licensure while assisting with reappointment credentialing. This position is also responsible for running and validating reports, to include but not limited to, ensuring applications are processed in a timely manner.

Essential Job Duties:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

  1. Reviews Joint Commission, CMS, and other regulatory requirements to ensure ongoing compliance of the Medical Staff Office processes and collaborates in the modification of the program as required.
  2. Manages and updates Credentialing Software database.
  3. Generates daily, weekly, and monthly reports for credentialing team regarding the status of initial and reappointment applications.
  4. Maintains internal database and assists other hospital departments with requests of practitioner information.
  5. Leads the OPPE/FPPE processes through report summaries, data analysis, and creating a structure to report peer review outcomes in a consistent manner and in accordance with medical staff policies.
  6. Prepares trending reports for Medical Staff Leadership review.
  7. Prepares detailed Credentials Report for Medical Executive Committee (MEC) and Board Committees.
  8. Analyzes existing departmental workflows from a lean management perspective to improve departmental efficiency and outcomes.
  9. Improves department systems by leveraging existing departmental and hospital technology.
  10. Performs data entry, organizes studies and reviews, and produces polished outcomes in the forms of memos, letters, graphs, charts, tables, and project A3s.

Educational/Experience Requirements:

  • Bachelor’s degree required in computer systems or information technology or equivalent
  • work experience.
  • Minimum of five (5) years’ experience in database management.
  • Background in data analysis preferred.
  • Minimum of one (1) year experience in hospital credentialing preferred.
  • Experience with performance improvement techniques preferred.

Working Conditions, Equipment, Physical Demands:

There is a reasonable expectation that employees in this position will not be exposed to blood-borne pathogens.

Physical Demands – Light Work

The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.

The above job description is an overview of the functions and requirements for this position. This document is not intended to be an exhaustive list encompassing every duty and requirement of this position; your supervisor may assign other duties as deemed necessary.


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Important Information about CPR (BLS) requirements for Anne Arundel Medical Center. (Note: this downloads a word document)