Job Description

Job Summary:

The Director of Medical Staff Services provides strategic leadership and oversight for all Medical Staff Services functions, including credentialing, privileging, medical staff governance, peer review support, accreditation compliance, and physician engagement activities. This position serves as a key advisor to physician leadership, executive leadership, and the Governing Board to ensure compliance with regulatory, accreditation, and organizational requirements while advancing the effectiveness of the organized medical staff and supporting high-quality patient care.

Experience/Qualifications:

• Minimum of 7 years of progressive Medical Staff Services experience in an acute care hospital environment.
• Minimum of 3-5 years of leadership, management, or supervisory experience overseeing Medical Staff Services operations and personnel.
• Demonstrated expertise in managing credentialing, privileging, appointment, and reappointment processes in accordance with regulatory and accreditation standards.
• Experience interpreting, implementing, and administering Medical Staff Bylaws, Rules and Regulations, policies, and governance requirements.
• Demonstrated responsibility for medical staff governance, accreditation compliance, physician peer review, OPPE, FPPE, focused evaluations, and professional practice evaluation processes.
• Experience working directly with and supporting Medical Executive Committees, Credentials Committees, Governing Boards, and executive leadership teams.
• Experience with credentialing software platforms, provider data management systems, and related healthcare technology applications.
• Proven ability to build and maintain collaborative relationships with physicians, advanced practice providers, hospital executives, department leaders, and external regulatory agencies.
• Strong knowledge of applicable Joint Commission, CMS, NCQA, DNV, and state regulatory requirements related to medical staff operations and credentialing.
• Demonstrated strategic leadership, operational management, and change management skills, with the ability to drive process improvement and ensure regulatory compliance across the medical staff services function.

Education:

• Bachelor's degree in Healthcare Administration, Business Administration, Public Administration, Nursing, Health Information Management, or a related field required.
• Candidates with significant progressive Medical Staff Services leadership experience, including responsibility for credentialing, accreditation compliance, medical staff governance, and physician peer review processes, will be considered in lieu of formal education.
• Master's degree strongly preferred.

License/Certifications:

• Certified Professional Medical Services Management (CPMSM) required.
• Candidates actively pursuing certification may be considered and must obtain certification within twelve (12) months of hire.
• Certified Provider Credentialing Specialist (CPCS) certification preferred.

Duties and Responsibilities:

• Provides strategic and operational leadership for the Medical Staff Services department, ensuring alignment with organizational goals, regulatory requirements, and best practices.
• Develops and implements long-range departmental goals, objectives, initiatives, and strategies to support the effective management of medical staff operations and governance.
• Serves as the organization's subject matter expert on medical staff affairs, credentialing, privileging, governance, accreditation, and regulatory compliance.
• Oversees all credentialing, privileging, appointment, reappointment, and provider enrollment activities, ensuring compliance with Medical Staff Bylaws, regulatory requirements, and accreditation standards.
• Oversees the administration and interpretation of Medical Staff Bylaws, Rules and Regulations, policies, procedures, and governance documents, providing guidance to physicians, medical staff leaders, and hospital leadership.
• Monitors and assesses emerging accreditation, regulatory, legal, and compliance requirements affecting medical staff governance, credentialing, peer review, and professional practice evaluation processes.
• Directs and oversees the operations of the Medical Executive Committee, Credentials Committee, Governing Board medical staff activities, and other medical staff committees, including agenda development, meeting coordination, documentation, follow-up, and implementation of committee actions.
• Serves as a strategic advisor to executive leadership, Medical Executive Committee, department chairs, and Governing Board members regarding medical staff governance, credentialing, privileging, peer review, and compliance matters.
• Oversees physician onboarding, orientation, and integration processes to support provider engagement, satisfaction, and organizational success.
• Provides leadership and oversight for physician peer review, OPPE, FPPE, focused evaluations, and professional practice evaluation processes, ensuring fairness, consistency, confidentiality, and regulatory compliance.
• Serves as a trusted liaison between hospital administration and the organized medical staff, fostering collaboration, communication, and engagement.
• Builds and maintains effective relationships with physicians, advanced practice providers, medical staff officers, department chairs, hospital executives, regulatory agencies, and external partners.
• Provides consultative guidance and support to physician leaders regarding credentialing, privileging, governance, peer review, and medical staff leadership responsibilities.
• Leads departmental process improvement initiatives focused on operational efficiency, physician satisfaction, service excellence, regulatory compliance, and risk reduction.
• Evaluates, implements, and optimizes credentialing software, provider data management systems, and other technology solutions supporting medical staff operations and governance.
• Develops and manages the department's operating and capital budgets, monitors financial performance, and ensures responsible stewardship of organizational resources.
• Establishes and monitors departmental performance metrics, quality indicators, and service standards, regularly reporting outcomes and recommendations to executive leadership.
• Promotes a culture of exceptional customer service, professionalism, accountability, collaboration, and continuous improvement throughout the Medical Staff Services department.
• Prepares and presents reports, analyses, and recommendations for executive leadership, Medical Executive Committee, Governing Board, and other committees as requested.
• Performs other duties as assigned.

Salary Range: $151,560 - $185,270