Manager, Medical Staff Services

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

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 Manager oversees personnel management, operational workflows, quality improvement initiatives, policy alignment, and performance metrics.
Maintains a strong business partnership with the BILH 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:

1.    Provides direct leadership and oversight of the Medical Staff Services Department (MSSD) team, ensuring effective daily operations, consistent application of policies, staff development, performance monitoring, and a commitment to operational excellence.
2.    Collaborates with the system Credentials Verification Office (CVO), Hospital Leadership, and Legal Counsel to support providers through the application process, ensuring timely appointment, reappointment, privileging, and management of credentialing expirables in compliance with Medical Staff Bylaws, Rules and Regulations, hospital policies, and applicable regulatory requirements, including those of The Joint Commission (TJC), the National Committee for Quality Assurance (NCQA), and state and federal agencies.
3.    Oversees staff and ensures the timely and accurate credentialing, recredentialing, and privileging of providers affiliated with the hospital.
4.    Manages and coordinates the timely submission of data and documentation for delegation audits by insurance plans, as applicable.
5.    Ensures the accuracy, completeness, and integrity of provider data entered into the credentialing database by the MSSD staff.
6.    Oversees and manages the maintenance and organization of electronic provider records in accordance with regulatory and organizational standards.
7.    Partners with system and physician leadership to develop new clinical privilege forms or revise existing forms to reflect current practice and regulatory expectations.
8.    Conducts regular team meetings to communicate updates, address concerns, and support team cohesion and performance.
9.    Conducts regular staff meetings.
10.    Responsible for recruiting, training, mentoring, and evaluating staff, as well as fostering their ongoing professional development.
11.    Participates in the development and monitoring of the departmental budget, including variance reporting and resource planning.

12.    Monitors departmental productivity and develops strategies to optimize operational effectiveness and efficiency.
13.    Develops new policies and procedures, and oversees the routine review, revision, and enforcement of existing policies to ensure regulatory and organizational compliance.
14.    Coordinates all aspects of assigned Medical Staff committee meetings—including the Credentials Committee, Medical Executive Committee, and Medical Staff Appointment Committee of the Board—ensuring accurate preparation of agendas, minutes, reports, and timely follow-up on actions.
15.    Oversees the implementation, coordination, and management of the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes.
16.    Maintains current knowledge of and ensures compliance with all relevant regulatory and accreditation standards, including TJC/DNV, NCQA, CMS, and state and federal laws, as well as Medical Staff Bylaws and hospital policies.
17.    Promotes a culture of excellence, professionalism, and customer service in all internal and external interactions and represents the organization positively in all external engagements.
18.    Performs other related duties as assigned to support departmental and organizational goals.

Organizational Requirements: 
1.    Maintain strict adherence to the BILH Confidentiality policy.
2.    Incorporate BILH Standards of Behavior and Guiding Principles into daily activities.
3.    Comply with all Departmental Policies.
4.    Comply with behavioral expectations of BILH.
5.    Maintain courteous and effective interactions with colleagues, providers, and BILH leadership.
6.    Demonstrate an understanding of the job description, performance expectations, and competency assessment.
7.    Demonstrate a commitment toward meeting and exceeding the needs of our customers and consis