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Medical Staff Compliance Specialist - Full Time - Day image - Rise Careers
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Medical Staff Compliance Specialist - Full Time - Day

Overview

Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

 

Come join our Amazing team here at Hackensack Meridian Health! We offer EXCELLENT benefits, Scheduling Flexibility, Tuition Reimbursement, Employee Discounts and much more!!!

 

The Medical Staff Office Compliance Specialist is responsible for reviewing Medical Staff regulatory compliance with Centers for Medicare and Medicaid, NJ Department of Health guidelines, and The Joint Commission standards, as well as adherence to the Medical and Dental Staff Bylaws, Rules and Regulations, and Policies.

Responsibilities

A day in the life of a Medical Staff Office Compliance Specialist at Hackensack Meridian Health includes:

 

  • Maintain current knowledge of Joint Commission and other regulatory requirements.
  • Preparation of files to present to the Joint Commission surveyor at triennial survey, all Disease Specific Certifications, and to the State Department of Health when requested.
  • Score compliance for Joint Commission preparedness through Accreditation Manager software.
  • Conduct annual report related to CMS audit to Corporate Compliance.
  • Attend all Joint Commission Steering Committee meetings and report on Medical Staff standards compliance.
  • Conduct audits to ensure Joint Commission compliance pertaining to providers’ credentials files.
  • Monitor and send Focused Professional Practice Evaluation forms to Department Chairs when the six-month monitoring period is coming to a close. Send follow-up Focused Professional Practice Evaluation forms to the department for any providers whose initial review resulted in a recommendation for continued monitoring.
  • Distribute departmental Ongoing Professional Practice Evaluation review spreadsheets to Chairs.
  • Monitor compliance of required Ongoing Professional Practice Evaluation submissions, sending reminders as needed.
  • Send Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation status reports to Chairs regularly.
  • Based on Department Chair feedback following the Ongoing Professional Practice Evaluation process, distribute clinical assessment forms to low-volume providers and follow up to ensure compliance.
  • Distribute Ongoing Professional Practice Evaluation forms to Allied Health Professionals and obtain Department Chair’s signatures on all Allied Health Professional’s Ongoing Professional Practice Evaluations.
  • Post Board of Trustees meeting, review relevant Credential Committee meeting minutes to launch Focused Professional Practice Evaluation for all new providers and additional privileges, as well as allied health professional Joint Protocol and Supervising Agreement changes.
  • Assist Legal and Risk departments with all requested documents for information pertaining to current or former members of the medical staff.
  • Administer and score conscious sedation test for physicians seeking conscious sedation privileges.
  • Prepare a list for conscious sedation monitoring at reappointment after verifying that the requirement of attestation has been met.
  • Enter all open Ongoing Professional Practice Evaluations for providers being reappointed into the reappointment workflow.
  • Review monthly reports to ensure compliance with privileges that require life support certification. If certification has lapsed, deactivate the privilege and reactivate when renewal is submitted.
  • Process all medical staff name changes (obtain legal document, verify all licenses, NPI, insurance, submit ticket to DTS).
  • Monitor stock of lab coats for the physician lab coat program. Order monthly to replenish. Check and organize the delivery of laundered coats twice a week. Order personalized coats for Chairs as needed. Approve invoices.
  • Assists with physician voting activities that include, but are not limited to, Castle Connolly Top Doctors, Castle Connolly Top Hospitals, US News and World Report Top Hospitals, New Jersey Monthly Top Doctors, and others as needed.
  • Verifies providers’ malpractice insurance coverage with insurance carriers.
  • Assists with numerous physician social and administrative functions hosted by the medical center.
  • Actively participates in the efficient operation of the department, including answering the Medical Staff Office phone as needed.
  • Other duties and/or projects as assigned.
  • Adheres to HMH Organizational competencies and standards of behavior.

Qualifications

Education, Knowledge, Skills, and Abilities Required:

  • High School diploma, general equivalency diploma (GED), and/or GED equivalent programs.
  • Minimum of 5 years of experience in a hospital setting.
  • Ability to work autonomously, set priorities, and make decisions independently.
  • Demonstrates critical thinking and problem-solving skills.
  • Demonstrates tactfulness and discretion.
  • Excellent written and verbal communication skills.
  • Proficient computer skills that include but are not limited to Microsoft Office and/or Google Suite platforms.

Education, Knowledge, Skills, and Abilities Preferred:

  • Bachelor’s degree in a related field.
  • Experience in a hospital setting working with senior leadership or a Department Chair.
  • Familiarity with hospital operations and regulatory bodies (e.g., The Joint Commission).
  • Knowledge of medical terminology.

Average salary estimate

$70000 / YEARLY (est.)
min
max
$60000K
$80000K

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Full-time, on-site
DATE POSTED
April 22, 2025

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