Vice President of Medical Staff Services and Privacy Program

About North Country Healthcare (NCH):

North Country Healthcare is a non-profit affiliation of four medical facilities, Androscoggin Valley Hospital, North Country Home Health & Hospice Agency, Upper Connecticut Valley Hospital, and Weeks Medical Center, located in the White Mountains Region of New Hampshire. NCH includes numerous physicians and medical providers at multiple locations. This leading comprehensive healthcare network which employs hundreds of highly-trained individuals delivers integrated patient care through three community hospitals, specialty clinics, and home health and hospice services. NCH remains committed to the health and well-being of the communities we serve. As a leader in a management position this role emphasizes advancing High-Reliability Organization (HRO) principles, embedding a culture of safety, accountability, and consistent high performance.

POSITION SUMMARY:

The Vice President of Medical Staff Services and Privacy Program is responsible for leading and managing the Medical Staff Services Program and overseeing the organization's privacy policies. This role ensures effective coordination of physician and allied health credentialing, supports medical staff governance, and maintains compliance with regulatory standards. Additionally, the position involves managing the organization’s privacy program, ensuring adherence to federal and state regulations.

ESSENTIAL QUALIFICATIONS

Education:

• Bachelor’s degree in healthcare administration, public health, business administration, or a related field is required.
• Master’s degree in healthcare administration, business administration, law, or a related field preferred.

Certification:

• Certification in Healthcare Privacy Compliance (CHPC) or Certified in Healthcare Compliance (CHC) preferred.
• Certification as a Certified Professional in Medical Services Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS) is advantageous.

Licensure:

• Association* accredited course in Basic Life Support (BLS) (for clinical staff), or Heartsaver CPR AED (for nonclinical staff), and renewal on a regular basis, with up to a three-month grace period after the expiration date.

Skills:

• Strong knowledge of healthcare regulations, including CMS standards, Medicare Conditions of Participation, and state-specific administrative rules.
• Demonstrated ability to manage complex credentialing and privileging processes.
• Proficient in managing privacy programs and ensuring compliance with HIPAA and other relevant privacy laws.
• Excellent leadership, strategic planning, and organizational skills.
• Strong analytical and problem-solving abilities to assess and mitigate risks effectively.
• Exceptional communication skills, both written and verbal, for interacting with various stakeholders and leading teams.
• Ability to collaborate effectively with compliance, legal, quality, and medical staff teams.

Work Experience:

• A minimum of 7-10 years of progressive experience in medical staff services management, including significant privacy program oversight responsibilities.
• Proven track record of successful leadership in a healthcare setting, with experience in accreditation and licensing processes.
• Experience in developing and implementing policies and procedures related to medical staff management and privacy compliance.
• Experience in managing teams, including supervising, delegating, and coordinating department-level operations.

ESSENTIAL FUNCTIONS:

Medical Staff Services Management:

1. Oversee the Medical Staff Services Program, ensuring smooth management of physician and allied health credentialing, as well as efficient flow of information through medical staff committees, the Medical Staff Executive Committee, and Governing Board.
2. Stay informed on standards from CMS, Medicare Conditions of Participation, New Hampshire Administrative rules, and other relevant regulations.
3. Prepare the organization for accreditation and licensing surveys related to medical staff functions.
4. Supervise, delegate, and coordinate work within the Medical Staff Services Department.
5. Collaborate with In-House Counsel to manage the medical staff application, reapplication, and mid-level provider credentialing processes.
6. Ensure compliance with regulatory requirements, accreditation standards, and medical staff bylaws, supporting staff in credentialing, privileging, peer review, and governance activities.
7. Direct credentialing and privileging processes in partnership with the credentialing team, ensuring timely, accurate, and compliant application processing.
8. Manage the credentialing database to maintain data integrity and security.
9. Partner with compliance, quality, and legal teams to mitigate risks in credentialing and privileging.
10. Provide strategic support to medical staff leadership, including MEC and Credentials Committee.
11. Develop leadership training programs for medical staff officers and committee chairs.
12. Collaborate with physician leaders on performance improvement initiatives and foster medical staff engagement.

Regulatory Compliance & Accreditation:

1. Coordinate medical staff documentation and audits to ensure continuous accreditation readiness.
2. Develop and maintain policies and procedures related to medical staff governance and performance evaluation.

Privacy Program Oversight:

1. Lead the development, implementation, and maintenance of the organization's privacy program per federal and state laws.
2. Manage all aspects of the privacy program, including daily operations, policy development, incident tracking, and compliance monitoring.
3. Serve as the NCH Privacy Officer, working with senior management, engineering, information security, and Compliance Officer to govern the privacy program.
4. Collaborate with the information security officer to align security and privacy compliance programs.
5. Establish and administer processes for investigating and acting on privacy complaints.
6. Conduct privacy risk assessments and implement remediation measures.
7. Oversee privacy training for the workforce and manage breach determination and notification processes.
8. Promote a culture of data privacy throughout the organization and stay informed of developments in privacy laws and regulations.
9. Cooperate with regulatory bodies during compliance reviews or investigations.

NON-ESSENTIAL FUNCTIONS

1. Performs additional duties as assigned.
2. Adheres to facility Values, Service Excellence and Standards of Excellence.