Medical Staff Services Director - Medical Staff

Education Requirements:
Bachelors Degree required in Healthcare Administration, Business Administration, or a related field.

Masters Degree preferred.

Experience:
Minimum of three to five years of experience in medical staff services, credentialing, provider enrollment, or health care administration required. Prior supervisory or leadership experience required, with demonstrated ability to manage staff, coordinate credentialing operations, maintain compliance with applicable standards, support medical staff committees, and collaborate effectively with physicians, advanced practice providers, hospital leadership, and external regulatory or accrediting agencies. Prefer CPCS and/or CPMSM certification through NAMSS. Certification will be required within 2 years of hire.

Required Skills:
Maintains current knowledge of practitioner credentialing criteria and processes in accordance with NCQA and Joint Commission standards. Demonstrate proficiency with computer applications, including Microsoft Word, Outlook, and Excel. Possesses excellent interpersonal and communication skills, with the ability to manage multiple priorities, complete tasks efficiently, and meet established deadlines. Uses discretion, sound judgment, and independent decision-making when resolving issues. Communicates and collaborates effectively with physicians and other health care professionals. Demonstrates the ability to lead teams and manage change in a professional and effective manner.

Supervises: Credentials Assistant and Medical Staff Services Administrative Assistant

Supervised By: Vice President of Quality and Patient Safety

Performance Standards:
• Organization Wide
Maintains a professional image.
Makes a conscientious effort to help maintain a clean, safe and secure environment.
Assumes responsibility for institutional requirements.
• Customer Service
Interpersonal skills.
Demonstrates pride in the organization.
Strives to work well as a team member.

Medical Staff Services Director:
• Medical Staff Governance: Supports medical staff governance functions, including Medical Executive Committee, Credentials Committee, medical staff departments and sections, bylaws, rules and regulations, and medical staff policy administration.
• Credentialing and Privileging Oversight: Oversees initial appointment, reappointment, privileging, and provider file maintenance. Supports focused professional practice evaluation, and ongoing professional practice evaluation processes in accordance with applicable standards and organizational requirements.
• Regulatory and Accreditation Readiness: Ensures ongoing compliance with applicable Joint Commission, NCQA, CMS Conditions of Participation, state licensure requirements, medical staff bylaws, and organizational policies.
• Supports provider Enrollment and External Credentialing Coordination as needed.
• Confidentiality and Peer Review Protection: Maintains strict confidentiality and appropriate handling of sensitive medical staff, credentialing, privileging, provider performance, and peer review information.
• Department Leadership: Provides leadership for Medical Staff Services team members, including workflow oversight, performance expectations, team member development, process improvement, and accountability for department goals and service standards.
• Technology and Data Integrity: Maintains responsibility for the accuracy, integrity, reporting, and effective use of credentialing systems, databases, and related documentation tools.
• Communication and Collaboration: Works effectively with physicians, advanced practice providers, medical staff leaders, senior leadership, legal, risk management, quality, compliance, revenue cycle, and external agencies to support timely and compliant credentialing and medical staff operations.
• Survey Readiness and Auditing: Conducts or coordinates ongoing audits, file reviews, tracers, survey preparation, and corrective action follow-up to ensure medical staff files and processes remain complete, accurate, and survey-ready.
• Decision-Making and Escalation: Interprets medical staff bylaws, rules and regulations, policies, and regulatory requirements and escalates credentialing, privileging, compliance, or provider-related concerns appropriately.

Performance Evaluation:
All Performance Standards are expected to be met and evaluation will be based on goals determined annually.

Perks/Benefits:

(for eligible employees):

Have optimal opportunity for career growth within our growing organization

Medical / Dental

Retirement Plan

PTO and paid life insurance