Description
Summary of Position:
The Director of Medical Staff Services provides system-level strategic leadership for medical staff governance, credentialing, privileging, and professional practice processes. This position oversees all medical staff employees and is responsible for the day-to-day operational oversight of Barton Health. This role also ensures consistent, compliant, and high-performing medical staff operations across hospitals and affiliated medical groups within the system while preserving strong physician partnerships and supporting local medical staff leadership. The Director serves as the system expert and executive partner responsible for designing, implementing, and continuously improving medical staff services infrastructure, including credentialing, privileging, appointment/reappointment processes, peer review support, medical staff governance operations, regulatory readiness, and physician engagement. This position promotes alignment between system standards and local medical staff needs, ensuring compliance with applicable regulatory and accreditation requirements while supporting efficient onboarding of physicians and advanced practice providers.
Qualifications
Education:
• Bachelor's degree in healthcare administration, business administration, nursing, or related field required.
• Master's degree in healthcare administration, business administration, nursing, or related field preferred.
Experience:
• Minimum 5 years of progressive experience in medical staff services, credentialing, provider enrollment, healthcare administration, or related healthcare operations leadership.
• Demonstrated experience supporting medical staff governance, credentialing, and privileging processes.
• Experience in a multi-hospital or integrated healthcare system preferred.
• Experience working with physician leadership and executive teams.
Knowledge/Skills/Abilities:
• Medical staff bylaws, governance structures, and committee operations
• Credentialing and privileging standards
• Joint Commission and CMS medical staff requirements
• Physician onboarding processes
• Professional practice evaluation systems
• Healthcare regulatory compliance
• Analyze operational data and develop improvement strategies
• Strong communication skills, both verbal and in writing with ability to present
• Credentialing software experience required; MD staff experience preferred
• Experience with ambulatory and hospital-based provider models preferred
• Experience supporting Critical Access Hospitals or rural healthcare systems preferred
Certifications/Licensure:
• Certified Provider Credentialing Specialist (CPCS) required
• Certified Professional Medical Services Management (CPMSM) preferred
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job, the employee is frequently required to walk, stand, sit, and talk or hear.
• The employee is occasionally required to use hands to finger, handle, feel or operate objects, tools, or controls; and reach with hands and arms.
• The employee is occasionally required to climb or balance; stoop, kneel, crouch, or crawl.
• Specific vision abilities required by this job include close vision, color vision, and the ability to adjust focus.
• The employee must occasionally lift and/or move up to 25 pounds.
Working Conditions
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Normal office environment. The noise level in the work environment is usually quiet to moderate while in the office.
• Occasional travel to various health system locations.
Essential Functions
1. Provides consistently exceptional care at all times.
2. Oversees and supports the medical staff office employees.
3. Recruits, develops, coaches, evaluates, and leads Medical Staff Services team members while fostering collaboration, accountability, professionalism, and continuous improvement.
4. Develops and implements system-wide Medical Staff Services strategy, operating models, and performance expectations while supporting local governance needs.
5. Establishes standardized processes, policies, workflows, and performance expectations across all hospitals and medical staff organizations, as applicable.
6. Leads the integration and optimization of medical staff operations across multiple campuses, states, and regulatory environments.
7. Supports effective committee operations and medical staff governance structures.
8. Serves as the primary administrative advisor for medical staff service operations to executive leadership, Chief Medical Officers, Associate CMOs, Chiefs of Staff, Vice Chiefs of Staff and medical staff leadership.
9. Oversees credentialing, privileging, appointment, reappointment, onboarding, and related performance metrics for physicians and advanced practice providers;
10. Ensures compliance with and is the expert subject matter for all regulatory agencies, such as The Joint Commission Medical Staff Standards, CMS Conditions of Participation, National Practitioner Data Bank (NPDB).
11. Maintains system readiness for regulatory and accreditation surveys related to medical staff services.
12. Supports effective medical staff governance structures across system entities.
13. Builds strong physician and stakeholder relationships, improves the physician experience, and supports physician leaders through education, communication, and operational tools.
14. Supports and partners with Quality, Risk, Patient Safety and physician leaders to provide effective professional practice evaluation processes, including items such as Focused Professional Practice Evaluation (FPPE), Ongoing Professional Practice Evaluation (OPPE), practitioner performance improvement activities, and collegial intervention processes.
15. Serves as a subject matter expert for Joint Commission surveys, CMS surveys, state regulatory reviews, and external accreditation activities.
16. Partners with Information Technology and vendors to optimize the credentialing platform(s) and reporting capabilities.
17. Develops dashboards, monitors key performance indicators, and leads process improvement, automation, workflow redesign, and technology optimization initiatives.
18. Responds to the needs of the department by performing other duties, as necessary.
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