Vice President of Medical Staff Services and Privacy Program

Weeks Medical Center • Berlin, NH

224d

About The Position

The Vice President of Medical Staff Services and Privacy Program is responsible for leading and managing the Medical Staff Services Program and overseeing the organization's privacy policies. This role ensures effective coordination of physician and allied health credentialing, supports medical staff governance, and maintains compliance with regulatory standards. Additionally, the position involves managing the organization's privacy program, ensuring adherence to federal and state regulations.

Requirements

• Bachelor's degree in healthcare administration, public health, business administration, or a related field.
• Master's degree in healthcare administration, business administration, law, or a related field preferred.
• Certification in Healthcare Privacy Compliance (CHPC) or Certified in Healthcare Compliance (CHC) preferred.
• Certification as a Certified Professional in Medical Services Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS) is advantageous.
• Strong knowledge of healthcare regulations, including CMS standards, Medicare Conditions of Participation, and state-specific administrative rules.
• Demonstrated ability to manage complex credentialing and privileging processes.
• Proficient in managing privacy programs and ensuring compliance with HIPAA and other relevant privacy laws.
• Excellent leadership, strategic planning, and organizational skills.
• Strong analytical and problem-solving abilities to assess and mitigate risks effectively.
• Exceptional communication skills, both written and verbal.

Nice To Haves

• Experience in developing and implementing policies and procedures related to medical staff management and privacy compliance.
• Experience in managing teams, including supervising, delegating, and coordinating department-level operations.

Responsibilities

• Oversee the Medical Staff Services Program, ensuring smooth management of physician and allied health credentialing.
• Stay informed on standards from CMS, Medicare Conditions of Participation, New Hampshire Administrative rules, and other relevant regulations.
• Prepare the organization for accreditation and licensing surveys related to medical staff functions.
• Supervise, delegate, and coordinate work within the Medical Staff Services Department.
• Collaborate with In-House Counsel to manage the medical staff application, reapplication, and mid-level provider credentialing processes.
• Ensure compliance with regulatory requirements, accreditation standards, and medical staff bylaws.
• Direct credentialing and privileging processes in partnership with the credentialing team.
• Manage the credentialing database to maintain data integrity and security.
• Partner with compliance, quality, and legal teams to mitigate risks in credentialing and privileging.
• Provide strategic support to medical staff leadership, including MEC and Credentials Committee.
• Develop leadership training programs for medical staff officers and committee chairs.
• Collaborate with physician leaders on performance improvement initiatives.
• Coordinate medical staff documentation and audits to ensure continuous accreditation readiness.
• Lead the development, implementation, and maintenance of the organization's privacy program.
• Manage all aspects of the privacy program, including daily operations, policy development, incident tracking, and compliance monitoring.
• Serve as the NCH Privacy Officer, working with senior management and Compliance Officer.
• Establish and administer processes for investigating and acting on privacy complaints.
• Conduct privacy risk assessments and implement remediation measures.
• Oversee privacy training for the workforce and manage breach determination and notification processes.

What This Job Offers

• Job Type: Full-time
• Career Level: Executive
• Industry: Hospitals
• Education Level: Bachelor's degree