Director Medical Staff

Director - Medical Staff
Remote Position

The Medical Staff Director provides strategic leadership, oversight, and management for all medical staff services, including credentialing, privileging, re-credentialing, and compliance with regulatory and accreditation standards. The Director serves as a liaison between the medical staff and hospital administration, ensuring effective communication and coordination of medical staff activities. This role involves managing a team of credentialing professionals and working closely with hospital leadership, physicians, and external agencies to ensure high standards of quality, efficiency, and compliance.

Duties and Responsibilities:

• Leadership and Management
  • Provide leadership and direction for the Medical Staff Services Department, ensuring efficient operations and compliance with hospital policies and industry regulations
  • Supervise and mentor credentialing coordinators and staff, providing guidance, training, and performance evaluations
  • Foster strong working relationships between the medical staff, hospital administration, and other departments to support the hospital's mission and goals
  • Develop and implement strategic initiatives related to medical staff functions in alignment with the hospital's overall objectives

• Credentialing and Privileging
  • Oversee the entire credentialing and privileging process for physicians, advanced practice providers (APPs), and other healthcare professionals
  • Ensure timely and accurate completion of credentialing and re-credentialing applications in compliance with Joint Commission standards, Centers for Medicare & Medicaid Services (CMS) regulations, and hospital bylaws
  • Maintain oversight of primary source verification, background checks, and all necessary credentialing documentation
  • Collaborate with department heads to evaluate provider qualifications and approve privileges based on education, training, experience, and current competency

• Medical Staff Governance
  • Serve as a key resource to the hospital's Medical Executive Committee (MEC), Credentials Committee, and other medical staff leadership committees
  • Prepare and distribute meeting agendas, application packets, reports, and minutes for medical staff committees and governance meetings
  • Ensure adherence to the medical staff bylaws, rules, and regulations in all medical staff-related activities
  • Facilitate the resolution of any credentialing or privileging issues in collaboration with the MEC and department chairs

• Regulatory and Accreditation Compliance
  • Ensure all credentialing and privileging processes comply with national accreditation standards (Joint Commission, CMS) and state and federal laws
  • Prepare for and participate in regulatory audits and accreditation surveys related to medical staff services
  • Stay informed of any changes in laws, regulations, or accreditation standards and implement necessary updates to policies and procedures
  • Maintain accurate and up-to-date credentialing files and ensure that all provider data is securely stored and readily accessible for audits

• Medical Staff Support and Development
  • Provide support to physicians and other medical staff members regarding credentialing processes, privileging criteria, and compliance requirements
  • Facilitate new physician onboarding processes, ensuring that all necessary documentation and training are completed prior to practicing at the hospital
  • Collaborate with hospital administration to develop programs and initiatives that promote physician engagement, retention, and professional development
  • Organize orientation programs and ongoing education sessions for the medical staff, focusing on regulatory changes and credentialing best practices

• Policy Development and Continuous Improvement
  • Develop, update, and implement policies and procedures related to medical staff credentialing, privileging, and governance
  • Identify and recommend process improvements to streamline credentialing workflows and enhance efficiency
  • Utilize data and reporting tools to track credentialing timelines, monitor compliance, and evaluate the effectiveness of the medical staff services department

• Communication and Collaboration
  • Act as a liaison between the medical staff, hospital leadership, and external regulatory agencies, ensuring seamless communication and alignment of priorities
  • Work closely with hospital leadership, department chairs, and the Chief Medical Officer (CMO) to address concerns related to medical staff performance, credentialing, and privileging
  • Collaborate with Human Resources, Legal, and Compliance departments to ensure alignment with institutional policies and legal requirements

• Budgeting and Resource Management
  • Manage the budget for the Medical Staff Services Department, ensuring that resources are allocated efficiently to meet department goals
  • Forecast and manage department expenses, including staffing, software systems, and other necessary resources
  • Oversee contracts and relationships with external vendors and credentialing verification organizations (CVOs) to ensure optimal service levels and cost management

Knowledge, Skills and Abilities:

• Strong leadership and managerial skills with the ability to lead a diverse team
• In-depth understanding of credentialing software systems (e.g., Cactus, MD-Staff, or similar platforms)
• Excellent verbal and written communication skills, with the ability to communicate effectively with physicians, hospital executives, and external agencies
• Strong organizational skills with attention to detail and accuracy
• Ability to manage multiple projects and prioritize tasks in a fast-paced healthcare environment

Work Experience, Education and Certifications:

• Bachelor's degree in healthcare administration, business, or a related field is required. Master's degree (MHA, MBA, or similar) is preferred
• Minimum of 5-7 years of experience in medical staff credentialing, with at least 3 years in a supervisory or management role
• In-depth knowledge of medical staff credentialing and privileging processes, including regulatory and accreditation requirements (Joint Commission, CMS)
• Experience working with hospital leadership, physicians, and governing boards
• Some light travel may be required

This job description is not to be construed as a complete listing of the duties and responsibilities that may be given to any employee. The duties and responsibilities outlined in this position may be added to or changed when deemed appropriate and necessary by the person who is managerially responsible for this position.