Director, Medical Staff Office

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

The System Medical Staff Office (MSO) Director provides strategic and operational leadership for Medical Staff Office operations across the Beth Israel Lahey Health (BILH) system, overseeing 11 hospital-based departments. This role is responsible for ensuring consistent, compliant, and high-quality medical staff services in support of credentialing, privileging, governance, regulatory readiness, and professional practice evaluation. The Director oversees personnel management, departmental budgets, operational workflows, quality improvement initiatives, policy alignment, and performance metrics. The ideal candidate is a collaborative and results-driven leader with deep expertise in medical staff services, accreditation standards, and health system operations.
The Director maintains a strong business partnership with the System Director of the Credentials Verification Office (CVO) to ensure seamless coordination between centralized credentialing functions and hospital-based medical staff operations. Together, they collaborate on aligned workflows, shared metrics, and regulatory compliance efforts that support a unified, system-wide approach to provider credentialing and governance.

Job Description:

Essential Duties & Responsibilities including but not limited to:

Leadership & Supervision:

• Provide system-level direction and supervision for Medical Staff Office managers and personnel across 11 hospitals.
• Develop and implement standardized policies, procedures, and workflows to ensure consistency and regulatory compliance across all sites.
• Foster a culture of accountability, service excellence, and continuous improvement.
• Conduct performance evaluations, support professional development, and foster a culture of accountability and continuous improvement.
• Provide back-up support to MSO leads, as needed, to maintain continuity of operations.

MSO Operations & Credentialing Oversight:

• Oversee and support all aspects of medical staff office operations and credential file review and approval process.
• Ensure timely, accurate, and compliant credentialing and privileging processes in collaboration with the Credentials Verification Office (CVO).
• Oversee management of provider expirables and initial and reappointment harmonization cycles across the system.

Governance & Committee Support:

• Support medical staff governance structures and ensure consistent processes for medical staff elections, officer appointments, and membership categories.
• Provide administrative and operational support for medical staff committees (e.g., Credentials Committee, MEC, Peer Review, Bylaws Committees).
• Oversee the maintenance of accurate documentation such as committee meeting minutes, reports, and committee actions.

Compliance, Quality, and Regulatory Readiness:

• Monitor and maintain compliance to applicable regulatory standards (NCQA, Joint Commission, and CMS) as well as applicable state and federal regulations.
• Participate in the review of credentialing delegation agreements between the hospitals and insurance plans.
• Lead preparation for regulatory surveys and audits related to medical staff functions
• Maintain current knowledge of applicable medical staff bylaws, rules and regulations, and associated medical staff policies and procedures.
• Coordinate quality assurance activities and support medical staff offices in preparation for surveys and audits.
• Oversee FPPE/OPPE programs in collaboration with quality and department chairs, ensuring ongoing professional practice evaluation is tracked, reported, and acted upon.
• Partner with system and site leadership to ensure provider quality concerns are escalated and addressed through appropriate channels.

Performance Monitoring & Metrics:

• Monitor team productivity and file turnaround times, ensuring performance aligns with established department standards and service expectations.
• Develop, maintain, and report on departmental metrics and performance goals.
• Monitor hospital and provider satisfaction and work collaboratively with CVO to address service issues.

Data & Systems Management:

• Oversee database entries to ensure accuracy, completeness, and consistency of provider records.
• Ensure the maintenance of electronic files in compliance with system standards and accreditation requirements.
• Assist with the development, optimization, and integration