Medical Staff Compliance Specialist

Hackensack Meridian Health; Hackensack (NJ); On-site; USD 60,000 - 80,000; Full time

Job summary

Join a leading healthcare organization as a Medical Staff Office Compliance Specialist. This role involves ensuring compliance with regulatory standards and supporting hospital operations. The ideal candidate will have significant hospital experience and strong communication skills. We offer competitive benefits and a collaborative work environment.

Benefits

Tuition reimbursement

Employee discounts

Scheduling flexibility

Qualifications

• Minimum 5 years hospital experience.
• Ability to work independently and prioritize.

Responsibilities

• Maintain knowledge of Joint Commission and regulatory requirements.
• Prepare files for Joint Commission surveys and audits.
• Audit provider credential files for compliance.

Skills

Critical thinking

Problem-solving

Communication

Education

High School diploma or GED

Bachelor’s degree in a related field

Tools

Microsoft Office

Google Suite

Job description

Description

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 support each other in succeeding. 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 serve our community. Together, we keep getting better — advancing our mission to transform healthcare and lead positive change.

Come join our amazing team at Hackensack Meridian Health! We offer excellent benefits, scheduling flexibility, tuition reimbursement, employee discounts, and much more!

Position Overview

The Medical Staff Office Compliance Specialist reviews medical staff regulatory compliance with CMS, NJ Department of Health, The Joint Commission, and adherence to bylaws, rules, regulations, and policies.

Responsibilities

• Maintain current knowledge of Joint Commission and other regulatory requirements.
• Prepare files for Joint Commission surveys, Disease Specific Certifications, and State Department of Health requests.
• Score compliance for Joint Commission preparedness using Accreditation Manager software.
• Conduct annual CMS audit reports for Corporate Compliance.
• Attend Joint Commission Steering Committee meetings and report on standards compliance.
• Audit provider credential files for compliance.
• Monitor and distribute Focused and Ongoing Professional Practice Evaluation forms to Department Chairs and providers, ensuring timely submissions and follow-up.
• Review Department Chair feedback post-evaluation, distribute clinical assessment forms, and follow up for compliance.
• Post-Board of Trustees meetings, review Credential Committee minutes to initiate evaluations and update protocols.
• Assist Legal and Risk departments with documentation related to medical staff members.
• Administer and score conscious sedation tests; prepare monitoring lists for reappointment.
• Enter reappointment evaluations, review monthly privilege compliance reports, and deactivate/reactivate privileges as needed.
• Process provider name changes, order lab coats, and verify malpractice insurance coverage.
• Support physician voting activities and assist with hospital functions and departmental operations.
• Participate in departmental activities, including answering phones and other assigned duties.
• Adhere to organizational standards and behaviors.

Qualifications

Required:

• High School diploma or GED.
• Minimum 5 years hospital experience.
• Ability to work independently, prioritize, and make decisions.
• Critical thinking and problem-solving skills.
• Tactfulness and discretion.
• Excellent communication skills.
• Proficient in Microsoft Office and Google Suite.

Preferred:

• Bachelor’s degree in a related field.
• Experience with hospital leadership or Department Chairs.
• Knowledge of hospital operations and regulatory bodies.
• Medical terminology familiarity.