Director Medical Staff Services
About The Position
The Director of Medical Staff Services provides leadership, operational oversight, and direction for Medical Staff Services to ensure effective medical staff governance and compliance with applicable regulatory, accreditation, and organizational requirements. The Director serves as an educational and consultative resource on credentialing, privileging, and medical staff governance for physicians and Advanced Practice Providers (APPs), collaborating with the Chief Medical Officer, Medical Staff, and Hospital Leadership. The position is accountable for executing core department functions while supporting the Organization’s broader vision and direction. The Director directly supervises the Medical Staff Services team and manages the department’s operating budget and Medical Staff funds.
Requirements
- A minimum of five years of progressive Medical Staff Services leadership experience at the Manager or Director level in an acute care hospital setting.
- Seven to 10 years of experience in medical staff credentialing and privileging.
- CPMSM certification from NAMSS, or ability to obtain it within 12 months of hire.
- Proficiency with credentialing and provider data management platforms, quality/peer review data tools, and Microsoft Office applications (Word, Excel, PowerPoint, and Outlook).
- Excellent written and verbal communication and interpersonal skills, including experience in a diverse professional setting.
- Knowledge of medical terminology and medical staff continuing medical education programs.
- Strong organizational and problem-solving skills to manage complex staff processes.
- Ability to analyze credentialing, privileging, and peer review data and prepare clear reports.
- Extensive expertise in credentialing and privileging in an acute care setting.
- Expert knowledge of applicable accreditation and regulatory requirements, including The Joint Commission, CMS Conditions of Participation, CDPH requirements, California Code of Regulations (Title 22), and relevant California statutes and codes.
- Comprehensive understanding of confidential peer review protections under California Evidence Code 1157, including OPPE, FPPE, and proctoring processes.
- Working knowledge of California medical staff reporting and verification obligations, including Business and Professions Code Section 805, NPDB querying and reporting, HCQIA peer review requirements, OIG/SAM and Medicaid exclusion screening, and verification with applicable licensing boards.
- Knowledge of NCQA credentialing standards and delegated credentialing agreements, and CMS/The Joint Commission requirements for telemedicine credentialing by proxy.
- Experience credentialing and privileging APPs, including Title 22-required Interdisciplinary Practice Committee processes.
- Ability to manage competing priorities and meet critical deadlines.
- Experience managing a departmental operating budget.
- Demonstrated experience directly supervising staff.
Nice To Haves
- Bachelor’s degree in healthcare administration or a related field; extensive equivalent experience may be considered in lieu of a degree.
- CPCS certification in addition to CPMSM.
- Experience with delegated credentialing, NCQA standards, and multi-site or health-system environments.
- Experience with CredentialStream and Midas.
Responsibilities
- Lead and provide operational oversight and direction for Medical Staff Services.
- Ensure effective medical staff governance and compliance with applicable regulatory, accreditation, and organizational requirements.
- Serve as an educational and consultative resource on credentialing, privileging, and medical staff governance for physicians and APPs.
- Collaborate with the Chief Medical Officer, Medical Staff, and Hospital Leadership.
- Execute core Medical Staff Services functions in alignment with the Organization’s vision and direction.
- Directly supervise the Medical Staff Services team, including hiring, performance management, coaching, and staff development.
- Manage the departmental operating budget and Medical Staff funds, including dues and stipends.
- Provide strategic guidance on Medical Staff Bylaws, Rules & Regulations, policies, and other governance processes.
- Manage medical staff meeting processes, including agenda preparation, scheduling, and minute-taking.
- Analyze credentialing, privileging, and peer review data and prepare reports for the MEC, Board of Directors, and Hospital Leadership.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Director
Education Level
No Education Listed
