Reports to the Director and manages the day-to-day operations of the Medical Staff Services Office. Works collaboratively with the Manager of Provider Enrollment, Medical Staff Leadership, and Hospital Leadership to organize and maintain systems that coordinate the credentialing and re-credentialing process for all Lahey Hospital and Medical Center (LHMC) providers.

Job Description:

Essential Duties & Responsibilities including but not limited to:

1. Provides direct leadership and oversight of the Medical Staff Services Department (MSSD) team, ensuring effective daily operations, consistent application of policies, staff development, performance monitoring, and a commitment to operational excellence.
2. Collaborates with the system Credentials Verification Office (CVO), Hospital Leadership, and Legal Counsel to support providers through the application process, ensuring timely appointment, reappointment, privileging, and management of credentialing expirables in compliance with Medical Staff Bylaws, Rules and Regulations, hospital policies, and applicable regulatory requirements, including those of The Joint Commission (TJC), the National Committee for Quality Assurance (NCQA), and state and federal agencies.
3. Oversees staff and ensures the timely and accurate credentialing, recredentialing, and privileging of providers affiliated with the hospital.
4. Manages and coordinates the timely submission of data and documentation for delegation audits by insurance plans, as applicable.
5. Ensures the accuracy, completeness, and integrity of provider data entered into the credentialing database by the MSSD staff.
6. Oversees and manages the maintenance and organization of electronic provider records in accordance with regulatory and organizational standards.
7. Partners with system and physician leadership to develop new clinical privilege forms or revise existing forms to reflect current practice and regulatory expectations.
8. Conducts regular team meetings to communicate updates, address concerns, and support team cohesion and performance.
9. Conducts regular staff meetings.
10. Responsible for recruiting, training, mentoring, and evaluating staff, as well as fostering their ongoing professional development.
11. Participates in the development and monitoring of the departmental budget, including variance reporting and resource planning.

12. Monitors departmental productivity and develops strategies to optimize operational effectiveness and efficiency.
13. Develops new policies and procedures, and oversees the routine review, revision, and enforcement of existing policies to ensure regulatory and organizational compliance.
14. Coordinates all aspects of assigned Medical Staff committee meetings-including the Credentials Committee, Medical Executive Committee, and Medical Staff Appointment Committee of the Board-ensuring accurate preparation of agendas, minutes, reports, and timely follow-up on actions.
15. Oversees the implementation, coordination, and management of the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes.
16. Maintains current knowledge of and ensures compliance with all relevant regulatory and accreditation standards, including TJC/DNV, NCQA, CMS, and state and federal laws, as well as Medical Staff Bylaws and hospital policies.
17. Promotes a culture of excellence, professionalism, and customer service in all internal and external interactions and represents the organization positively in all external engagements.
18. Performs other related duties as assigned to support departmental and organizational goals.

Organizational Requirements:
1. Maintain strict adherence to the BILH Confidentiality policy.
2. Incorporate BILH Standards of Behavior and Guiding Principles into daily activities.
3. Comply with all Departmental Policies.
4. Comply with behavioral expectations of BILH.
5. Maintain courteous and effective interactions with colleagues, providers, and BILH leadership.
6. Demonstrate an understanding of the job description, performance expectations, and competency assessment.
7. Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to BILH customer service standards.
8. Participate in departmental and/or interdepartmental quality improvement activities.
9. Participate in and successfully completes Mandatory Education.
10. Perform all other duties as needed or directed to meet the needs of the department.

Key Relationships:

• CVO Executive Director - Reports to and collaborates closely with the Executive Director of System Provider Credentialing and Medical Staff Services to implement strategic initiatives, standardize operations, and ensure alignment with system priorities and regulatory requirements.
• CVO Manager - Maintains a strong partnership to coordinate MSSD operations with centralized credentialing functions. Works jointly to align credentialing workflows, ensure regulatory readiness, and share responsibility for the provider lifecycle and compliance.
• CVO Database Manager - Collaborates to ensure the accuracy, integrity, and usability of credentialing data systems. Partners on database workflows, reporting, and continuous improvements that support both operational and regulatory needs.
• CVO Staff - Partners with credentialing specialists and analysts to support the seamless processing of initial and reappointment files and to maintain readiness for regulatory reviews.
• BILH Medical Staff Services Leadership - Develops and maintains collaborative relationships with peer MSSD leaders across the system to support consistency, information sharing, and best practice adoption.
• Network Hospital Leadership - Serves as a key liaison to hospital leadership, supporting their oversight of medical staff governance, credentialing and privileging decisions, and medical staff-related quality and compliance efforts. Maintains a dotted-line reporting relationship to the hospital Chief Medical Officer (CMO) and Chief Executive Officer (CEO) to ensure local alignment and responsiveness to site-specific priorities.

Minimum Qualifications:

Required Qualifications:

• Associates degree required; Bachelor's degree preferred.
• 3-5 years related work experience required and 1-3 years supervisory/management experience required
• Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications; May produce complex documents, perform analysis and maintain databases.

Preferred Qualifications:

• Experience in a health care setting

Pay Range:
$80,000.00 USD - $130,000.00 USD

The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.