Medical Staff Services Director
Freeman Health SystemAbout the role
Our Mission
To improve the health of the communities we serve through contemporary, innovative, quality healthcare solutions.
Schedule: Full Time (40hrs/week)
What You'll Do
The Director of Medical Staff Services is responsible for the strategic leadership, management, and oversight of all Medical Staff Office (MSO) operations. This position ensures compliance with accreditation, regulatory, and organizational requirements related to medical staff governance, credentialing, privileging, provider enrollment, and peer review activities. The Director serves as a key liaison between hospital administration, medical staff leadership, governing boards, and providers while fostering a culture of operational excellence, service, accountability, and continuous improvement.
Responsibilities:
Direct all Medical Staff Office operations and personnel.
Develop, implement, and maintain medical staff bylaws, policies, rules, and regulations.
Serve as liaison between hospital administration, medical staff leadership, and providers.
Advise executive leadership on medical staff governance and compliance matters.
Support Medical Executive Committee (MEC), Credentials Committee, Peer Review Committee, and governing board activities.
Oversee credentialing, recredentialing, privileging, and provider enrollment processes within MSO.
Ensure compliance with Joint Commission and/or HFAP, CMS, state regulations, and organizational requirements.
Establish credentialing and privileging standards and oversight these standards and the reporting thereof.
Monitor application turnaround times and departmental performance metrics.
Ensure timely processing of initial appointments, reappointments, focused professional practice evaluations (FPPE), and ongoing professional practice evaluations (OPPE).
Maintain continuous survey readiness for Joint Commission and/or HFAP, DNV, CMS, and state regulatory agencies.
Lead responses to accreditation surveys and regulatory audits.
Ensure compliance with medical staff accreditation standards and provider governance requirements.
Monitor regulatory changes and implement necessary operational updates.
Coordinate Medical Staff committees and governance activities.
Prepare agendas, reports, meeting materials, and board presentations.
Maintain official medical staff records and documentation.
Ensure board approvals and privileging/credentialing recommendations are accurately documented.
Develop and implement departmental goals, budgets, and strategic initiatives.
Identify operational improvement opportunities and implement best practices.
Leverage technology to improve credentialing efficiency and compliance.
Lead implementations and optimizations of credentialing software platforms (e.g., MD-Staff, Sail Point, EPIC).
Recruit, mentor, develop, and evaluate Medical Staff Office personnel.
Establish department performance goals and accountability measures.
Promote a culture of excellence, customer service, and continuous improvement.
Manage departmental budget and resource allocation.
Requirements:
Bachelor's degree in Healthcare Administration, Business Administration, Nursing, or related field required.
Minimum five (5) years of experience in a director-level leadership role within Medical Staff Services.
Experience managing medical staff credentialing and privileging processes within an acute care hospital or integrated health system.
Experience supporting Joint Commission, DNV, HFAP, NCQA, CMS, and state regulatory surveys.
Occasional travel to affiliated hospital, clinics, and medical staff meetings may be required.
Preferred Requirements:
Master's degree preferred.
Minimum ten (10) years of progressive healthcare leadership experience preferred.
Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) or Certified Professional Coder or equivalent healthcare certification.
Multi-hospital health system experience.
Experience leading
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