Manager-Medical Staff Services
Listed on 2026-02-28
-
Healthcare
Healthcare Administration, Healthcare Management
Overview
Manager-Medical Staff Services
Job Code: 21495
FLSA Status
Job Family: NURSING
Job Summary:
Responsible for establishing, contributing to and maintaining continuity in the planning, development and implementation of standards applicable to the medical staff organization, relating to credentialing, re-credentialing, quality and administrative functions. Ensures compliance with the accrediting and regulatory agencies (i.e. JC, CMS, NCQA, if applicable, State and Federal) in regard to credentialing while developing and maintaining a working knowledge of statues and law.
Key functions include taking budgetary responsibility for the department as well as supervisory responsibility for department staff. This position develops operational and informational plans, coordination of information flow between medical records, risk management, utilization and other departments/services performing quality improvement functions for the medical staff, and assures development of and compliance with operating and capital budgets and achievement of financial performance.
Performs all other duties as assigned.
- Manages the Medical Staff Services Department including planning, organizing, directing, controlling, and evaluation. Establishes priorities and secures resources to achieve the goals and objectives of the department. Prepares and is responsible for the department's operational and capital equipment budgets.
- Supports functions of the organized medical staff as outlined in the Bylaws, Rules & Regulations, and Policy and Procedures. Ensures appropriate development and maintenance of current department policy and procedure manuals. Ensures timely and accurate credentialing and privileging process and utilizes software systems to manage and track the process.
- Develops and maintains effective working relationships with the Medical Staff leadership; providing consultative expertise, administrative and other delegated support as necessary for them to fulfill their obligations. Supports communication with the Medical Staff through use of Medical Staff Newsletter, electronic communication boards and other methods as required.
- Interfaces effectively with other departments to facilitate the flow of utilization, privilege status, outcome, and all other medical staff quality improvement data to facilitate the reappointment and focused review process
- Oversees Medical Staff minutes and quality improvement data/documentation and assure compliance with Joint Commission standards.
- Actively participates in the Joint Commission/State licensure accreditation survey. Interacts with surveyors to demonstrate compliance with standards to achieve accreditation and maintain deemed status for Centers for Medicare and Medicaid (CMS).
- Oversees IRB, CME, FDA accreditation, Medical Staff Orientation, unreferred call schedule, and additional operational functions of the department as required.
Minimum
Required:
1 year Healthcare/Medical-Medical Staff Services required or 1 year Healthcare/Medical-Other
Preferred/Desired:
General Management experience
Description
Minimum
Required:
High School diploma or equivalent required
Preferred/Desired:
Bachelor’s degree in Business or Healthcare related field
Description
Minimum
Required:
Preferred/Desired
Special SkillsDescription
Minimum
Required:
Previous experience with Windows software, and credentialing software. Must demonstrate understanding of the medical staff organization responsibilities and its related bylaws rules/regulations that govern the organization, Joint Commission standards/survey process/scoring guidelines, other regulatory agency requirements/standards; medico-legal issues and laws relating to Medical Staff organization. Familiarity and understanding clinical information systems and data management techniques. Exposure to and responsible for handling confidential information with high degree of sensitivity and diplomacy.
Professional attitude and appearance at all times.
Preferred/Desired:
LicensureDescription
Minimum
Required:
Certification in Medical Staff Credentialing required within 3 years of employment.
Preferred/Desired:
Reporting RelationshipsDoes this position formally supervise employees? If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.
Reporting Relationships: YES
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