Medical Staff Services Manager

Good Shepherd Health Care•Hermiston, OR

2d•Onsite

About The Position

The Medical Staff Services Manager is responsible for the management and oversight of all Medical Staff Services functions for Good Shepherd Health Care System. This role ensures compliance with Medical Staff Bylaws, Rules and Regulations, accreditation standards, and applicable federal, state, and local regulations related to credentialing, privileging, peer review, and medical staff governance. The Medical Staff Services Manager serves as a primary liaison between the Medical Staff, hospital administration, governing body, and regulatory agencies. This position supervises the Credentialing Coordinator and ensures accurate, timely, and compliant credentialing and recredentialing processes for all physicians and advanced practice providers.

Requirements

Bachelor’s degree in a related field preferred; equivalent combination of education and experience may be considered.
Minimum of four (4) years’ experience in Medical Staff Services, credentialing, or healthcare setting.
Experience working with physicians, administrators, and board members.
Medical terminology required.

Nice To Haves

Certification by the National Association of Medical Staff Services (NAMSS) as a Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Staff Services Management (CPMSM) is strongly preferred or encouraged within a defined timeframe.
Affiliation with NAMSS and applicable state medical staff services associations is strongly encouraged.
Supervisory or lead experience preferred.

Responsibilities

Manages the daily operations of the Medical Staff Services Department in accordance with Medical Staff Bylaws, Rules and Regulations, hospital policies, and accreditation standards.
Acts as executive secretary to elected Medical Staff officers and committee chairs.
Prepares agendas, attends meetings, records minutes, and ensures follow-up for the Medical Executive Committee, Credentials Committee, and other medical staff committees as assigned.
Manages the flow of information and recommendations from medical staff committees through the Medical Executive Committee to the Board of Trustees.
Develops, maintains, and coordinates review of medical staff governance documents, including bylaws, rules and regulations, and related manuals.
Serves as a resource to Medical Staff leadership regarding interpretation and application of bylaws and policies.
Oversees credentialing, recredentialing, and privileging processes for all physicians and advanced practice providers.
Supervises the Credentialing Coordinator, including work prioritization, training, performance oversight, and quality review.
Ensures credentialing files are complete, accurate, current, and compliant with CMS, DNV/NIAHO, CAH, and state regulatory requirements.
Coordinates review and evaluation of applications for appointment, reappointment, and clinical privileges through appropriate medical staff leadership and committees.
Ensures timely tracking and management of expiring licenses, certifications, privileges, and other required credentials.
Maintains practitioner data within credentialing and hospital information systems to accurately reflect current status and governing body actions.
Serves as the subject matter expert for medical staff-related accreditation and regulatory requirements.
Coordinates preparation for and participation in accreditation and regulatory surveys (e.g., DNV/NIAHO, CMS, CAH).
Ensures Medical Staff Services operations remain survey-ready at all times.
Facilitates the development and implementation of corrective action plans related to medical staff services findings or deficiencies.
Maintains policies and procedures to support ongoing compliance with applicable laws and regulations.
Coordinates with Quality, Risk Management, and Medical Staff leadership to support FPPE, OPPE, and peer review processes.
Ensures appropriate documentation, confidentiality, and compliance with peer review and professional practice evaluation requirements.
Assists medical staff leaders with tracking and reporting performance data required for reappointment and privileging decisions.
Serves as a liaison between the Medical Staff, hospital administration, and governing body regarding medical staff services matters.
Collaborates with Human Resources, Information Technology, Quality, Risk Management, and other departments to support practitioner onboarding, access, and compliance.
Provides education and guidance to medical staff leaders and hospital departments related to credentialing, privileging, and medical staff governance processes.
Develops, manages, and monitors the Medical Staff Services budget, ensuring alignment with operational goals and organizational priorities.
Works in coordination with and with assistance from the Accounting/Finance Department to prepare budget proposals, track expenditures, forecast resource needs, and ensure fiscal accountability.
Identifies cost‑effective process improvements and resource utilization strategies.
Maintains a working knowledge of applicable federal, state, and local laws and regulations related to Medical Staff Services.
Supports the hospital mission, vision, values, policies, and procedures.
Participates in required education for accreditation programs as applicable to the position.
Performs other related duties as assigned by the Chief Medical Officer.