The incumbent works independently and has multiple responsibilities with varying degrees of complexity, which require: knowledge of Joint Commission on the Accreditation of Hospitals (TJC) Standards, the medical By-Laws, and VHA credentialing and privileging (C&P) requirements for processing of initial and renewal packets and scopes of practice; application of the compliance knowledge in the risk analysis of documents submitted for the C&P process and information obtained from mandated queries.

Duties

The incumbent is assigned to the Medical Staff Office, which is under the Chief of Staff at a VA Medical Center (VAMC) and is responsible for providing administrative and technical direction and support to the credentialing and privileging (C&P) operations. The C&P Specialist is aligned to and supervised by the C&P Manager. The Medical Staff Office is responsible for the C&P process of VAMC clinical services providers including full-time, part-time, temporary, intermittent, contract, without compensation (WOC), fee basis and telehealth Licensed Independent Providers (LIPs), as defined in the VAMC Medical Staff Bylaws. Major duties include, but are not limited to the following: Assists the C&P Manager/Analyst in developing short- and long-term goals necessary to accomplish the mission of the C&P program. Assists in identifying the resources necessary for accomplishing the mission and function of the credentials and privileging program. Serves as SME in the field of credentials and clinical privileging. Keeps leadership and appropriate administrative staff informed of program changes, new regulatory requirements, and policies and procedures pertaining to the C&P process. Assists C&P Manager/Analyst in drafting local credentialing processes and Medical Staff Bylaws in compliance with all applicable regulations. Receives and reviews correspondence and communications for the C&P function and determines which items require immediate attention and which are confidential in nature. Receives and reviews VetPro reports detecting problem areas requiring further investigation. Upon identification of a problem, researches reference materials, regulations, and standards to identify appropriate action necessary to correct the problem. Issues of a serious nature are elevated to the supervisor for guidance. Ensures accurate provider data is entered into and maintained in the VetPro computer program. Informs C&P Manager/Analyst of trends identified, audit results and identified problems that may affect a provider's privilege status. Manages provider applications (initial and renewals) for LIPs C&P within the VAMC. Provides guidance and instruction to hospital staff in completing the required documentation of establishing privileges for LIPs. Upon receipt of individual credentials' files for review, incumbent ensures primary source verification to include, but not limited to, state licenses, DEA license, certifications, medical specialty training, and board certifications. Primary source verification includes, but may not be limited to, the American Medical Association, NPDB, state licensing agencies, specialty certification boards, universities, DoD and healthcare facilities. Coordinates with clinical service departments on findings of clinical care competency. Assures application packages and other documents meet technical requirements per specialty of provider and assures application folder and database account (VetPro or other internal databases and spreadsheets) meet technical requirements. Communicates with LIPs to assure timely completion of applications and VetPro requirements. Provides oversight to application process; analyzes exceptions and deviations in expected application process; determines course of action and makes recommendations. Determines processes for coordination of incoming data and documents from a variety of sources. Reviews documents and applications for omissions and inconsistencies and assures data entry is complete and accurate to meet VHA policy and regulation, and TJC standards. Reviews documents received and determines course of action based on information provided within documents Promotion Potential: The selectee may be promoted to the full performance level without further competition when all regulatory, qualification, and performance requirements are met. Selection at a lower grade level does not guarantee promotion to the full performance level. Work Schedule: Monday - Friday, 8:00 am - 4:30 pm Telework: Not authorized Virtual: This is not a virtual position. Position Description/PD#: Health System Specialist/PD99876A Relocation/Recruitment Incentives: Not authorized Financial Disclosure Report: Not required Physical Requirements: The work is mostly sedentary. Occasionally, light physical effort may be required, such as that involved with walking, stair climbing, and carrying of light office items.

Requirements

Qualifications

To qualify for this position, applicants must meet all requirements by the closing date of this announcement, 02/27/2024. Time-In-Grade Requirement: Applicants who are current Federal employees and have held a GS grade any time in the past 52 weeks must also meet time-in-grade requirements by the closing date of this announcement. For a GS-7 position you must have served 52 weeks at the GS-5. For a GS-9 position you must have served 52 weeks at the GS-7. The grade may have been in any occupation, but must have been held in the Federal service. An SF-50 that shows your time-in-grade eligibility must be submitted with your application materials. If the most recent SF-50 has an effective date within the past year, it may not clearly demonstrate you possess one-year time-in-grade, as required by the announcement. In this instance, you must provide an additional SF-50 that clearly demonstrates one-year time-in-grade. Note: Time-In-Grade requirements also apply to former Federal employees applying for reinstatement as well as current employees applying for Veterans Employment Opportunities Act of 1998 (VEOA) appointment. Candidates must meet the following Individual Occupational Requirement: Candidates must meet the following minimum qualifications of the 0671 Health System Administration Series. Undergraduate and Graduate Education: Major study -- hospital administration, public health administration, or related fields such as business or public administration with course work in health care administration. OR Specialized Experience: Progressively responsible analytical or administrative, or clinical management or supervisory experience in the health care field. This work may have been performed in an operating health care facility or a higher organizational echelon with advisory or directional authority over such facilities. Work must have involved a close working relationship with facility managers and analysis and/or coordination of administrative, clinical, or other service activities, and provided knowledge of the following: Missions, organizations, programs, and requirements of health care delivery systems; Regulations and standards of various regulatory and credentialing groups; and Government-wide, agency, and facility systems and requirements in various administrative areas such as budget, personnel, and procurement. Special Provision for Inservice Placement: Successful completion of an agency-sponsored on-the-job training program may be substituted for qualifying experience, provided it included a formal individualized training plan. Such a training program must have been conducted in an operating health care system and included: Assignments providing a knowledge of basic health system administration philosophies, practices, and procedures, and basic government administrative policies and requirements; Practical assignments providing an opportunity to apply health system administration skills and principles (as the individual progresses, work assignments must be characteristic of the grade level to which he or she is assigned); and Oversight by an experienced health system administrator with periodic evaluation of the individual's progress and appropriate adjustment of the training program. In addition to the Individual Occupational Requirement candidates must also meet the following specialized experience and/or education: GS-7 - Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-5 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Providing administrative and technical direction and support to program operations. Verifying information related to education, training, licensure, from state licensing agencies, specialty certification boards, universities, and other healthcare facilities. Educating departments and managers on program requirements and changes. Managing and tracking complex data from multiple sources. Utilizing organization credit card to make purchases ensuring funds are available and payments are reconciled timely. (MUST REFLECT IN RESUME NO ASSUMPTIONS WILL BE MADE) OR, Education: You must have successfully completed 1 full year of graduate level education or superior academic achievement in a major field of study related to the work of the position which provided the knowledge, skills, and abilities necessary to perform the duties of this position. (NOTE: TRANSCRIPTS MUST BE SUBMITTED WITH THE APPLICATION MATERIALS. CONFERRAL OF DEGREE(S) EARNED SHOULD BE PRESENT ON TRANSCRIPT(S). UNOFFICIAL TRANSCRIPT(S) IS OK.) OR, Combination: Applicants may also combine education and experience to qualify at this level. [Note: To combine education and experience, first determine how much of the qualifying experience and education you have, as a percentage of what is required for each. Add the percentages together, and if the total is 100% or more, then the combined education and experience is qualifying for the position. EX: To compute the percentage, divide your total months of qualifying experience by 12. Then divide your semester hours of education beyond the first 18 semester hours (i.e. beyond the first year) by 18. Add the two percentages together. The total percentage must equal at least 100% to qualify.] GS-09 - Specialized Experience: You must have one year of specialized experience equivalent to at least the next lower grade GS-07 in the normal line of progression for the occupation in the organization. Examples of specialized experience would typically include, but are not limited to: Applying analytical and evaluative methods and techniques to issues and/or toward the planning and accomplishment of routine and complex work assignments, such as advising leadership on documentation requirements for provider profiling and competence. Use of software applications such as word processing, data bases and internet database applications for data entry, file maintenance and data retrieval/analysis. Attention to detail to analyze applications, documents, files and other material pertaining to a Credentialing & Privileging program. Education: You must have successfully completed master's or equivalent graduate degree or 2 full years of progressively higher level graduate education leading to such a degree or LL.B. or J.D., if related to such a degree in a major field of study related to the work of the position which provided the knowledge, skills, and abilities necessary to perform the duties of this position. Combination: Applicants may also combine education and experience to qualify at this level. You will be rated on the following Competencies for this position: AuditingDecision MakingPlanning and Evaluating Note: A full year of work is considered to be 35-40 hours of work per week. Part-time experience will be credited on the basis of time actually spent in appropriate activities. Applicants wishing to receive credit for such experience must indicate clearly the nature of their duties and responsibilities in each position and the number of hours a week spent in such employment. For more information on these qualification standards, please visit the United States Office of Personnel Management's website at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/.

Education

A transcript must be submitted with your application if you are basing all or part of your qualifications on education.

Note: Only education or degrees recognized by the U.S. Department of Education from accredited colleges, universities, schools, or institutions may be used to qualify for Federal employment. You can verify your education here: http://ope.ed.gov/accreditation/. If you are using foreign education to meet qualification requirements, you must send a Certificate of Foreign Equivalency with your transcript in order to receive credit for that education. For further information, visit: http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-visitus-forrecog.html.

Contacts

• Address San Francisco VA Medical Center 4150 Clement Street San Francisco, CA 94121 US
• Name: Diana Avila-Linaja
• Phone: 650-694-6000 X15130
• Email: [email protected]