Director Medical Staff Services (Hospital Experienced)

Tenet Healthcare   •  

Delray Beach, FL

Less than 5 years

Posted 301 days ago

This job is no longer available.

  The Director of Medical Staff Services is responsible and accountable for implementing and monitoring the development, planning, and operational management of the Medical Staff Office and committee structure to enable fulfillment of Medical Staff duties and obligations as defined by national regulatory agencies and the Medical Staff Bylaws and Rules and Regulations, as delegated by the hospital Governing Board.  Promotes and enhances good communication and a positive working relationship between hospital Administration and the Medical Staff.   Essential Job Duties:1.       Assures the efficient operational management of the Medical Staff Services Department.

      • Maintains confidentiality.
      • Provides administrative support to the Medical Staff, provides resources needed for the Medical Staff, enabling them to fulfill their duties and obligations as defined by National Regulatory Agencies, and the Medical Staff Bylaws, Rules & Regulations.
      • Acts as liaison for the Medical Staff and Delray Medical Center Administration; coordinates the flow of information between all parties to ensure optimal responsiveness and efficiency, using appropriate channels of communication.
      • Assures fully functioning work environment to provide maximum efficiency
      • Collaborates with the Medical Staff leaders, the Medical Staff, and Administration to improve systems/processes.
      • Maintains office systems, i.e., filing system, archives; ensures adequacy of inventory of supplies and materials on an ongoing basis.
      • Sets up systems for and maintains a continual flow of information.
      • Identifies areas needing improvement and implements changes as required.
      • Answers inquiries from physicians, patients, and staff in a timely manner, providing accurate information. 2.       Oversees Medical Staff meeting requirements pursuant to the Medical Staff Bylaws.
  • Prepares and maintains clear, concise, and accurate annual calendar, coordinating schedule to ensure all required meetings are planned appropriately and in a timely manner.
  • Coordinates meeting schedule with Administration to ensure the availability of adequate meeting space.
  • Provides accurate information to Nutritional Services with proper notification.
  • Distributes calendar to the Medical Staff, hospital personnel and other appropriate services on a monthly basis. 3.       Provides administrative support, guidance and resources to the Medical Staff for formal and informal meeting activities, as assigned.
  • Consults with Medical Staff officers to properly prepare for each meeting.
  • Provides adequate notification to Committee members to promote high meeting attendance.
  • Provides committee members with sign-in sheet, maintains accurate computerized record of attendance for all assigned Medical Staff meetings.
  • Prepares agenda cognizant of all unfinished business and recommends from other committees.
  • Facilitates efficiently run meeting by planning, developing and providing each Committee member with a neat and accurate packet of supporting documentation and relevant information, per established policies and procedures.
  • Attends assigned meeting and takes verbatim dialogue.
  • At conclusion of meeting, collects all confidential information and disposes of properly.
  • Prepares transcribed minutes accurately, efficient and in a timely manner in CRAE format to meet Joint Commission standards; maintains current and confidential file of Committee minutes, in an organized fashion.
  • Processes follow-up requirements as necessary to facilitate effective Medical Staff activity, documentation and communication per established policies and procedures.
  • Following Executive Committee, prepares monthly President of the Medical Staff Report for submission to Governing Board, including all required information and supporting documentation.
  • Following Governing Board meeting, ensures appropriate notification to all applicable parties of Governing Board action, per established policy and procedure, within five (5) working days of Governing Board meeting.
  • Monitors reports and minutes of all assigned Committee meetings to ensure reports of quality improvement activities are included in the monthly reports to the Medical Executive Committee and the Governing Board. 4.       Assists President of Medical Staff in preparing the committee appointments prior to the beginning of each Medical Staff year.
  • Responsible for selected and confidential correspondence and special projects as requested by the officers and/or chairmen in relation to department and/or committee work. 5.       Medical Staff Bank Account
  • Responsible for collecting, depositing, and posting Medical Staff monies, (i.e., annual dues; and, for disbursement of monies, i.e., donations, payments.) 6.       Development of the Medical Staff Bylaws, Rules and Regulations, and Policies and Procedures.
  • Maintains Medical Staff Bylaws, Rules and Regulations; analyzes for compliance with accreditation and regulatory agencies.
  • Advises Medical Staff Leadership and Administration of variances.
  • Maintains an accurate computer and hard copy of existing and proposed Medical Staff Bylaws, and Rules and Regulations.
  • Coordinates the distribution of all appropriate changes to the Medical Staff, general counsel and hospital personnel, as indicated. 
  1. Directs and supervises Medical Staff Office personnel and activities of the Department.
  • Conducts monthly department meetings and documents minutes for it.
  • Selects, trains, orients and assigns Department staff; determines qualifications and competence levels; motivates Department Staff to perform in an efficient and professional manner; ensures training needs are met.
  • Initiates or makes recommendations for personnel actions.  Personnel actions, including promotions, transfers, hires, terminations, corrective action and pay adjustments are recommended or initiated, in compliance with Hospital Policies and Procedures and applicable labor laws.
  • Ensures employees in area of responsibility meet all conditions of employment as outlined
  • Prepares and issues employee evaluations within appropriate timeframe, and ensures ongoing competency assessment.



  1. Fiscal Responsibilities
  • Prepares, monitors and meets budgeting requirements and productivity standards
  • Consistently remains within established Department budget.
  • Ensures capital expenditures do not exceed budget
  • Ensures operating costs do not exceed budget
  • Ensures wages/salaries do not exceed budget
  • Budget completed timely
  • Emergency Service Call rotation schedule
  • Ensures proper coverage in each specialty as per Medical Staff Bylaws and Rules and Regulations.
  • Tracks and communicates ER call schedule changes in a timely manner.

 10.      Assists the Medical Staff in adherence to Joint Commission requirements and prepares reports to satisfy these requirements resulting in Medical Staff compliance to standards.

      • Maintains Joint Commission scoring guidelines for the Medical Staff to ascertain compliance with Joint Commission Standards.
      • Serves as a resource on Joint Commission Standards pertaining to the Medical Staff as demonstrated by compliance to standards. 11.      Customer Services
  • Achieves hospital-wide ytd patient/physician/employee satisfaction measurement system (PSMS) scores
  • Demonstrates willingness to act as a representative of the Tenet Code of Standards, and promotes same within Department
  • Actively participates in Performance Improvement Group teams
  • Handles difficult situations in a discreet and professional manner; maintains professional attitude and appearance at all times  12.      Assists all patients, family members, physicians, visitors and employees in a professional and courteous manner.
  • Extends special attention and sensitivity to all patients, visitors, physicians, and fellow employees.
  • Assists in maintaining an atmosphere of cooperation with other departments and allied professionals.
  • Demonstrates respect and cooperation in all staff relationships, and a genuine willingness to prevent or resolve inter-personal conflicts.
  • Demonstrates the ability to participate in and/or implement team decisions.
  • Actively participates in and encourages actions that promote good public relations with patients' families, visitors and the community.
  • Works together in a spirit of teamwork.
  • Shares information on a "need to know" basis.  

13.      Complies with all policies and procedures that pertain to HIPAA, including the minimum    necessary requirements for this job position

  • As part of the requirements for this position, the employee has limited access to the medical record for the purpose of providing clerical support to the Medical Staff Services Dept, including credentialing, and state reporting requirements
  • Limits the protected health information (PHI) disclosed or requested to the amount reasonably necessary to achieve the purpose of the request.  Disclosures or requests that occur on a routine or recurring basis include:  patient name, medical record number for the purpose of peer review.
  • Criteria established to limit the PHI disclosures/requests to that which is reasonably necessary includes access to patient name, and medical record number, and the Rally system.   14.       Positively promotes the services and image of the department while effectivelydeveloping and maintaining a network of working relationships with all thoseserved by the department.
  • Serves as a role model for excellence in customer services, which includes: prompt, courteous, competent service for all those served by the department; assisting with problem solving, providing resource services. 
  1. Continues to improve professional growth, knowledge of job to maintain efficiency and effectiveness of the Medical Staff Office by belonging to professional organizations, attending seminars, and reads journals and publications addressing medical staff activities. 
  2. Performs and fulfills all HICS (hospital incident command system) responsibilities, assignments, tasks, and roles as directed and needed by the facility in times of emergency and/or disaster. Responsible for knowing the Hospital’s emergency codes, including the purpose and appropriate action for each, and adheres to the Hospital policies and procedures for each emergency code.  Accepts/participates on assigned Team for Hurricane response. Comprehensive Benefit Package availableDelray Medical Center is a tobacco free and drug free workplace 


EDUCATION: Minimum: High School graduate Preferred: Associates Degree or higher degree  

EXPERIENCE:  Minimum:  Three (3) years in Medical Staff Services   REQUIRED CERTIFICATION/LICENSURE/REGISTRATION:               

CMSC or Certified Professional Credentialing Specialist (CPCS)  #LI-VM1

Job: Non-Clinical/Administrative

Primary Location: FL-Delray Beach

Hospital/Facility: Delray Medical CenterJob Type: Full-timeShift Type: Days

Job Number:1805000616