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Participate and regularly meet with administration to evaluate progress of physicians and hospital-based physician programs. 

Assist in the professional development and growth of individual providers. 

Assists the Regulatory officer and regularly reviews TJC standard policies, procedures, and medical protocols regarding patient care. 

Provides guidance to hospital-based physician program services to include policies, personnel, services, quality assurance monitoring, and education. 

Regularly assess hospital medical staff perceptions and needs of the program to assure a harmonious working relationship, provides leadership to practitioners resulting in overall hospital improvement by:  

Encouraging teamwork and participation 

Assisting in any necessary face to face or phone interviews, recruitment, placement, counseling, or termination of physicians 

Orienting new providers and monitoring their ongoing compliance with policies and procedures 

Responsible for receiving, investigating and settling in conjunction with the President of the Medical Staff, all grievances or questions of policy concerning and/or raised by medical providers/physician extenders. 

Review, investigate, manage, and report all complaints concerning physician staff arising from patients, medical staff, or administration. Appropriate complaint disposition will follow medical staff policies regarding professionalism, provider health and bylaws. 

Regularly attend other medical staff committees 

Work closely with COO/CEO to achieve the hospital’s goals for contract stability and optimal contract management. 

Provides overall medical leadership to all medical staff members. 

Work cooperatively and supportively with the administration and physicians to assure services are available, cost effective, meeting quality and regulatory guidelines. 

Supervises and assists Risk Manager in ongoing monitoring and compliance of the hospital’s risk management program. 

Interacts with the hospital medical staff and specialists to assure appropriate and timely patient care, patient transfers, and patient referrals. 

Reporting responsibilities for the Quality Department, with focus on CMS Star Rating, Leapfrog Safety Score and Mortality reporting. Includes oversight of TJC Disease Specific Certifications in CHF, AMI, Total Joint Replacement, Stroke, Spine. Review of registry outcomes for AMI, CathPCI, TAVR, LAAO, STS. Engage with the medical staff, as needed, for Performance Improvement activities. 

Work with Infection Prevention to prevent Hospital Acquired infections, participate in detailed case analysis, as needed. 

Lead the Professional Practice Evaluation Committee in multispecialty peer review, OPPE & FPPE activities, appropriate by service line. 

Reporting responsibilities for the Pharmacy and operational support 

Executive oversight of Graduate Medical Education (DIO, Internal Medicine and Transitional Year), ensuring ACGME accreditation standards are maintained. 

Doctor of Medicine or Doctor of Osteopathic Medicine 

Knowledge of Hospital Medical Staff Operations 

Knowledge of Hospital Medical Staff and Medical Executive Committee Function 

Ability to interact and facilitate communication between health care professionals and Healthcare Administration 

Board Certification by ABMS recognized Board 

Active GA Medical Licensure 

Experience on Medical Staff Governance and Credentialing 

Experience in Clinical Practice Management