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Medical Service Corps Administrator St. Louis
3 months ago
Description of Services:
The contractor shall meet all requirements per the basic contract and provide professionally and technically qualified individual(s) to perform all tasks in the following paragraphs to fulfill the requirements of this task order. The contractor personnel shall oversee the day-to-day Credentialing and Privileging (C&P) program operations encompassing all aspects of inpatient, emergency and/or ambulatory care and support functions within the Saint Louis Medical Military-Civilian Partnership (STL-MCP) through USAFSAM/711th HPW via the Office of Military Medicine (OMM), which oversees clinical rotations by military medical personnel from multiple units at non-military hospitals in Eastern Missouri and Southern Illinois. Supports multiple medical units, two civilian universities (Saint Louis University & Washington University in Saint Louis) and their civilian medical facilities & affiliates [SSM Health Saint Louis University Hospital (SLUH) & Barnes Jewish Hospital (BJH)] and the Mercy Hospital System hereby referred to as Civilian Healthcare Organizations (CHCOs). Enables timely, high quality health care which is essential to sustaining clinical currency and medical readiness skills for permanent and rotating privileged providers. Strengthens collaboration with CHCOs in line with the National Defense Authorization Act 2017 Mission Zero Initiative. As the OMM credentialing and privileging subject matter expert the position interprets general regulations, instructions, rules, and local policies and ensures operations are in line with regulatory and mission requirements. Maintains effective communication with military providers, nurses, technicians, and administrators, as well as applicable CHCO management and staff on C&P/medical staff issues to create a culture of safety, empower frontline staff to identify and mitigate organizational risks, and improve patient outcomes and health care delivery through the establishment of an integrated and collaborative organization-wide approach. Coordinates with CHCOs to identify potential program deficiencies and develop initiatives for improvements, resolve problems, and enhance OMM program effectiveness. Develops new office processes and business procedures to improve OMM program objectives and operations. Balances workload and provides overall direction and vision to staff on a wide range of education and administrative issues. Conducts, interacts, and projects a professional Air Force image when interacting as an OMM & USAFSAM intermediary representative with all military/civilian functional organizations. Will perform personnel management duties: providing advice and assistance to the OMM Director and Deputy Director and clinical staff on overall technical management and administrative taskers sent
from the affiliate programs to ensure timely completion as it pertains to the C&P program. Assists with updating and reviewing annually the Training Affiliation Agreements (TAAs) and Memoranda of Agreement (MOAs & MOUs) with all civilian organizations, which require significant coordination with each legal division(s) and the United States Air Force. The contractor personnel shall interface with 711HPW/ET leadership and staff, other professionals across both the Air Force Research Laboratory, Air Force Medical Services, the Defense Health Agency, the Department of Defense, and CHCO leadership, staff, and subject matter experts.
Mandatory Qualifications:
- Excellent interpersonal skills are required to serve as a liaison between multiple military and civilian medical partnerships. Excellent writing and verbal communication skills are required. Proficiency with word processing software, spreadsheet software, and SharePoint applications is required.
- Requires a Bachelor's degree in business, management, or a health-related field, and at least 2 years of experience in the field or in a related area(s).
- Knowledge and understanding of applicable Air Force and professional standards is mandatory. Knowledge of military and civilian guidelines that govern policy and procedure, successful completion of USAFSAM's and Department's orientation programs is required.
- Knowledge of federal and civilian accrediting agency standards, state/national requirements and other regulatory agency requirements regarding licensing and certification, and legislation and laws pertaining to health care delivery systems.
- Knowledge of credentialing and privileging functions, theories, and techniques, executive orders, regulations, policies, and concepts that pertains to credentialing and privileging management. Knowledge of and skill in applying analytical and evaluative methods and techniques to issues or studies concerning the efficiency and effectiveness of Credentialing and Privileging Program operations.
- Contractor must have a Non-Disclosure Agreement in place with their company, and the company must provide a copy to the Program Manager of this task order. This is necessary to mitigate transfer of any confidential, proprietary and/or sensitive information while in this position.
- Knowledge applicable to a wide range of health care administration and management functions to include pertinent laws, regulations, policies and precedents which affect the use of program and related support resources.
- Knowledge of medical terminology and procedures sufficient to oversee appropriateness of privileges requested, to interpret and identify discrepancies, and facilitate interaction with medical professional at all levels of the organization, DHA, AFMS, and CHCOs
- Extensive knowledge of Inspection standards and guidelines, Title IV of Public Law 99-660, DoD regulations and directives, Accreditation Standards (i.e., TJC), and state laws pertaining to medical staff issues and their impact on the facility’s credentialing and privileging policies, procedures, and programs in order to evaluate compliance with Air Force, governmental, and private health inspection agency policies and guidelines, advise the military commanders, OMM Board of Directors, military and/or civilian Chiefs of Staff, and/or civilian organizations’ Chief Executive Officers on program deficiencies and provide recommendations for implementation of corrective actions.
- Knowledge of procedures of the National Practitioner Data Bank (NPDB), Federation of State Medical Boards (FSMB), Drug Enforcement Administration (DEA) as relates to the issuance and maintenance of health care provider DEA licensure, Provider Enrollment, Chain and Ownership System (PECOS), the Health Insurance Portability and Accountability Act (HIPAA) as it relates to Protected Health Information (PHI) and state and local regulatory agencies in order to safeguard patient safety and confidentiality during provision of care by all healthcare providers rotating through the CHCOs and maintain verification and continuity of licensure, certification, and adverse reporting for clinicians.
- Expert knowledge of credentials and privileges management as well as program inter-relationships with quality assurance, performance improvement/risk management, organizational structures, and mission requirements and objectives of the DHA, Air Force Medical Service (AFMS), and CHCOs to evaluate suboptimal clinician practice trends.
- Knowledge of and ability to effectively use automated data systems (e.g., JCCQAS, Carepoint, and EHR systems (Epic)) to measure the effectiveness, efficiency, and productivity of the healthcare delivery system and make recommendations to resolve problems.
- Knowledge of analytical processes and tools sufficient to research and identify complex problems or unusual situations regarding quality improvement and the credentials and privileging process within CHCOs.
- Knowledge and ability to apply executive orders, regulations, policies and concepts pertaining to credentials and privileging management to analyze, evaluate and upgrade specialty-specific credentialing requirements and privileging lists, including skill in explaining and defending recommendations.
- Knowledge of health care directives related to legal practices and their association to adverse privileging actions.
- Skill in organization and communication to develop working relationships and administer programs with diverse military, civilian, professional, and technical populations, to include verbal and writing skills to prepare presentations and/or briefings.
Highly Desired Qualifications:
- Knowledge and skill in applying analytical and evaluative methods and techniques sufficient to identify problems or unusual situations regarding administrative issues.
- Skill in developing interpersonal relationships, maintaining good working relationships, and working cooperatively as a liaison between various military organizations and civilian medical facilities.
- Skill and ability to collect and analyze program data and report results of continuous monitoring activities for use in organizational decision-making.
- Certification in Certified Professional Credentials Specialist and/or Certified Professional Medical Services Management is desired.
- Master's degree in business, management, or a health-related field, and at least 2 years of experience in the field or in a related area(s).
Tasks:
- Manages and Administers the C&P program.
- Serves as the authority for Air Force Medical Service (AFMS) C&P matters for the Office of Military Medicine (OMM). The Office of Military Medicine is the office with responsibility for one of the largest military-civilian medical collaborations in the US, created to maximize military medical activities at civilian hospitals with a focus on collaboration and readiness.
- Serves as primary interface between the OMM Director, his/her executive staff, medical staff members, legal consultants, military medical units, CHCOs and other agencies [e.g., civilian, Air Force (AF), Army, Navy, Reserve, Guard, Veterans Affairs (VA)] regarding credentials, privileging and certification issues.
- As the OMM C&P subject matter expert the position interprets general regulations, instructions, rules, and local policies and ensures operations are in line with regulatory and mission requirements. Provides authoritative technical advice to the OMM, military medical units, CHCOs and other professional staff members regarding medical staff credentialing, privileging, and professional certification programs.
- Coordinates and ensures proper collaboration between all agencies participating in the OMM program ensuring that all C&P documentation for military members (privileged and non-privileged providers, nurses and technicians from multiple specialties) from all organizations represented is complete and accurate; allowing them to conduct training at CHCOs in specialized hospital sections such as; trauma, emergency room, burn and inpatient units, intensive care, obstetrics/gynecological, general medical/surgical floors, pediatrics, etc.
- Manages initial, annual, biennial, and other privileging actions of healthcare providers to ensure short- and long-range plans for implementation for mission success and all regulatory requirements are met.
- Researches, clarifies, analyzes, and applies accrediting agency standards, DoD, AF, and CHCO regulatory policies and guidance. Interprets and incorporates pertinent C&P directives and policy guidelines from higher authorities into OMM policy for approval by the OMM Director and Board of Directors. Interprets regulatory guidance to ensure USAFSAM personnel and rotators and CHCOs provide the highest quality medical care possible to achieve/maintain mandated accreditation.
- Develops new office processes and business procedures to improve OMM program objectives and operations. Coordinates office workload and provides overall support to staff on a wide range of administrative processes.
- Prepares for surveys/inspections and may serve as an internal resource and liaison to accrediting/inspection agencies. Prepares and presents command, director and/or Chiefs of Staff-level briefings necessary for the orderly function of the C&P program.
- Advises health care providers of medical staff by-laws, rules, regulations, and criteria required for requests for and delineation of clinical privileges for the provision of patient care.
- Produces C&P reports for leadership and executive staff of USAFSAM, OMM Board of Directors, and CHCOs for use in making performance-based decisions about the organization. Prepares and presents orientations, formal presentations, and training to the executives, medical professional staff members, and support staff members of the OMM and CHCOs to educate them on the C&P criteria ensuring mission requirements are met.
- Administers and maintains all documentation for privileged and non-privileged rotators/trainees, in support of an AFMS training platform, while ensuring that medical military staff comply with any health/safety requirements and/or trainings set forth by The Joint Commission, CHCOs, SLUSOM, and/or WashUSOM.
- Completes and audits documentation to determine accuracy of onboarding process and records. Introduces rotators/trainees to key personnel and schedules their initial training and orientation requirements. Keeps senior management informed of program progress and advises of any significant developments that may impact operations.
- Coordinates and collaborates with other departments within the OMM, USAFSAM, Defense Health Agency (DHA) and Air Force Medical Readiness Agency (AFMRA) to verify adherence to Department of the Air Force Instructions (DAFIs), DoD Instructions and Manuals, Defense Health Agency (DHA) Memorandum of Medical Quality Assurance and Clinical Quality Management in the Military Health System (MHS) in support of patient safety related to accreditation and compliance programs.
- Utilizes various databases, software programs and automated data systems, including but not limited to, Electronic Health Care Records Systems [i.e., Epic, Composite Health Care System (CHCS) and Armed Force s Health Longitudinal Technology Application (AHLTA) or Genesis], health care monitoring tools/applications (e.g., Carepoint), and other related programs. Uses Joint Centralized Credentials Quality Assurance System (JCCQAS) in the collection, tracking, and reporting of required data by military Credentialing, Privileging and Risk Management Offices on Health Care Practitioners within their facilities and for readiness and humanitarian missions.
- Assists with updating and reviewing annually the Training Affiliation Agreements (TAAs) and Memoranda of Agreement (MOAs & MOUs) with all civilian universities/military organizations, which require significant coordination with each legal division(s) and the United States Air Force.
- Plans, organizes, and oversees tactical aspects of the C&P program regarding military medical providers rotating through CHCOs and affiliates to ensure timely, high quality health care which is essential to sustaining clinical currency and medical readiness skills for permanent and rotating privileged providers.
- Assists with on-boarding at CHCO facilities and ensures provider profiles are created in the Electronic Health Record System, allotting appropriate order entry and access for providers.
- Perform the following administrative management service-oriented tasks: answering the office phones, typing, filing, building and maintaining simple databases, ordering office supplies, constructing training and in processing packets for all rotators.
- Contractor shall build Word documents, spreadsheets using Excel Program, and presentations using PowerPoint.
- Obtains, Primary Source Verifies, and monitors all required credentials. Performs all additional required queries. Analyzes and evaluates the credentials processes in meeting established goals and objectives set by the Medical Staff Managers at participating CHCOs.
- Effectively communicates with the Commanders and Department Heads to ensure essential data is accessible for the award of privileges, appointment, and re-appointment of providers to the medical staff.
- Works closely with the commanders and department chairman as they interrelate to the credentials process and accurately provide pertinent provider information and feedback. Provides ongoing updates/changes of the C&P processes.
- Remains current in all aspects of accreditation, DoD, and Air Force Medical Service (AFMS) credentialing standards to ensure compliance by the participating facilities.
- Manages Confidential Databases Required for C&P
- As OMM authorized agent and certifying official, queries and processes confidential information concerning provider’s credentials from numerous national data banks and registration entities. Responsible for security of the provider’s credentials and activity files.
- Initiates applications for fee-exempt Drug Enforcement Administration (DEA) registration and primary point of contact for Provider Enrollment Change and Ownership System (PECOS) as needed. Ensures Criminal History Background Checks in regard to C&P are conducted in accordance with guidance of AF, DHA, and CHCOs on designated applicants
- Analyzes background information used in establishing competence of medical, dental and allied health care professionals. Verifies that applicant professional credentials comply with DoD, AFMS, and CHCO accrediting agencies’ C&P policies and regulatory entities ensuring the safety of the patients.
- Provides advice and guidance to the OMM and CHCOs’ Credentials Function regarding a provider’s ability to clinically practice and perform requested procedures. Provides credentials guidance, ensures adherence to credentials requirements, eligibility criteria for the position and award of clinical privileges.
- Manages the credentials (i.e., training, licensure, certification, and/or registration) of health care personnel, tracks expiration dates and provides notifications prior to the deadlines, and initiates timely and appropriate actions regarding deficient provider credentials.
- Obtains continuing medical education and continuing health care education and validates training of providers requesting delineated medical privileges for appropriateness, continuity, and authenticity to ensure complete compliance with all credentialing policies for the OMM and CHCOs.
- Develops data management tools to ensure essential clinical performance assessment/improvement data is accurately presented and available to all personnel involved in initial award or renewal of privileges and appointment to the medical staff.
- Monitors and reports the status of peer review, Ongoing and Focused Professional Practice Evaluations for timely submissions. Monitors adverse trends to facilitate safe, reliable, quality healthcare and submits a report for review by the OMM and CHCOs’ Chief of the Medical Staff as well as the USAFSAM leadership.
- Ensures completion of all aspects of the reappointment of members of the medical staff and advises the OMM and CHCOs on these issues.
- Monitors for compliance due-process procedures and timelines for professional staff adverse action/impaired provider situations. Provides C&P guidance on all adverse action/impaired provider matters for privileged and non- privileged provider staff per regulatory guidelines and due process procedures.
- Coordinates with health care providers regarding matters of a sensitive nature, interacts with practitioners undergoing disciplinary actions or those identified as impaired providers when required.
- Analyzes significant data relative to providers’ performance to track adverse trends/ incidents. Maintains evidence, documents and communications related to actual ligation, investigation, and/or privileging actions affecting health care providers if required.
Base Support:
The contractor shall be provided office/laboratory space, furniture and equipment, routine office/laboratory supplies, computer hardware and software necessary to perform tasks described in this performance work statement. The government will also provide telephone service and access to a fax machine and a copier as required. All software and hardware, passwords/access to military Internet/E-mail and applicable database will be available within the scope of the contract. The contractor shall comply with local, AF and DoD policies.
General Information:
- Work will be accomplished at Saint Louis University Hospital located at South Grand Blvd, St. Louis, MO 63104 beginning on 16 September 2024.
- Temporary alternate work locations may be assigned as circumstances dictate by the Contracting Officer Representative.
- Work schedule is normally Monday – Friday, 7:30 AM – 4:30 PM (ET); however, there may be times when it is necessary for the contractor to work after duty hours in support of specific tasks. Although schedule may have to be flexible, it will not exceed 40 hours per week.
U.S. Citizenship:
Employee must be a U.S. citizen. For the purpose of base and network access, possession of a permanent resident card (“Green Card”) does not equate to U.S. citizenship.
TRAVEL:
No travel is anticipated for this effort.
SECURITY:
All contractor personnel require a minimum of a Tier 1 background check (T1)/SF85 for any position that requires access to the internet, use of automated information systems to cover standalone computers or unescorted entry into restricted or controlled areas prior to reporting for duty in support of any requirement. The investigation is not for a security clearance; it is for a position of trust. This is a mandatory requirement set forth in DoDM 5200.02_AFMAN 16-1405, Air Force Personnel Security Program.
The contractor shall provide OPSEC protection for all sensitive/critical information and indicators involved in execution of this contract/Task Order, as defined by AFI 10-701 (Operations Security). 711 HPW Critical Information and Indicators are protected under the 711 HPW Operations Security Program and the 711 HPW Critical Information and Indicators List (CIIL). Contractor employees granted access to critical information and indicators shall be provided initial OPSEC training by the 711 HPW OPSEC Coordinator upon in-processing and prior to being granted access to CIIL items related to the contract/Task Order. The contractor shall also participate in 711 HPW’s annual OPSEC training and education programs, which includes periodic updates and refresher training on CIIL items applicable to the contract/Task Order. The 711 HPW OPSEC coordinator shall evaluate the OPSEC posture of AF contract activities and operations.
Deliverable:
Contractor Progress, Status and Management Report (PSMR).
On a monthly basis, the contractor shall provide a status report. The information will be on project status and describe the work accomplished. The contractor shall also identify any issues/problems anticipated in schedule or cost ceiling during the next reporting period.
The report shall have five sections:
- Project Title, Time Period of report, Date
- Performance: Current status of deliverables, measured against project expectations.
- Schedule: Have scheduled activities and milestones been completed on or before time, and impact of delays.
- Costs: Are there any actual or significant deviations, are significant costs adequately explained in terms of project plans? (i.e., large initial equipment purchase, followed by labor related costs.)
- Risk: Are there known or anticipated opportunities or events that will or can affect project.
Point of Contact for Immediate Consideration:
Art Mata
amata@reef-sys.com