Position Summary: The Senior Director, Medical Staff Services is the administrative liaison between the Medical Staff and Hospital Administration and the Board of Directors. Leadership accountability is expected in managing practitioner competency systems; policies, procedures and legal governance documents; support of Medical Staff Leadership; Medical Staff Services (MSS) operations; Medical Staff and hospital collaboration and leadership by demonstrating current practices and by using and integrating technology.  The Director is responsible for developing systems that support the Medical/Professional Staff and Hospital’s mission and strategic plan.  A key performance area is regulatory and accreditation knowledge and compliance.


The Senior Director, Medical Staff Services supervises the activities of the Director, Manager, Coordinator, Specialists and/or Assistant as applicable.


Essential Job Functions:

Major Competencies

  1. Plans, organizes and directs a comprehensive credentialing program
    • Directs all aspects of the credentialing functions for appointments and reappointments.
  2. Designs, implements and manages an objective, criteria-based clinical privileging system
  • Ensures that clinical privileges performed are criteria-based and reflective of current services offered by the organization and encompasses licensed independent practitioners (LIPs) and advanced practice practitioners (APPs).
  • Works in conjunction with the hospital quality department on aspects related to the privileging functions relative to peer review and professional performance profiles.
  • Remains up- to- date on new procedures, techniques and equipment relative to Medical Staff Services and general knowledge of procedures, techniques and equipment that may impact Medical Staff privileging.
  • Controls the monitoring of procedure-established criteria to ensure that practitioners meet qualifications for eligibility to request and retain specific privileges.
  • Works with other hospital personnel to ensure that practitioners practice within the scope of their privileges.
  1. Interprets, develops and implements practices of all systems and functions to ensure continuous compliance with applicable regulatory agencies and accrediting bodies as applicable e.g., CMS, DNV JC, NCQA, AOA-HFAP, AAAHCDNV, etc.
    • Provides ongoing education to team and Medical Staff Leaders as necessary.
    • Participates on hospital compliance teams and in regulatory and accreditation surveys, as needed.
  2. Collaborates with other hospital personnel regarding performance improvement data to help Medical Staff Leaders make informed decisions regarding practitioner competence
    • Collaborates with key staff on managing an ongoing reporting process that is accurate, timely and action driven.
  1. Controls and directs the administrative support of governance documents
    • Ensures that all governance documents, policies, procedures, rules and regulations are compliant and current.
    • Protects permanent records by managing a secure record retention process.
  1. Plans and manages an effective Medical Staff meeting management system
  • Directs meeting activities (agenda development, documentation, follow-up, communication).
  • Provides guidance on accreditation, regulatory issues, medico-legal implications, national standards of care, best practices, meeting outcomes and resolution.
  1. Plans and manages the administrative support to Medical Staff   Leadership allowing them to effectively carry out their duties and responsibilities
  • Collaborates, develops and implements long and short-term goals.
  • Manages processes related to investigative, disciplinary and legal proceedings, such as fair hearing and appeal.    



  1. Directs and manages the strategic and daily activities of the department
  • Responsible for adequate staffing and efficient use of staffing resources
  • Establishes standards and analyzes work procedures that promote leading practices and champions innovation.
  • Controls and manages budget.
  1. Directs the administrative interface with Medical Staff Leaders and Medical Staff organization and hospital administration, the Governing Body and hospital departments to assure and enhance effective relationships
  • Serves as a liaison between Medical Staff and Administrative Leadership.
  1. Supports education, professionalism, practice-based learning and systems-based learning
  • Responsible for recruiting, training, mentoring, evaluating and disciplining departmental staff.
  • Cultivates positive interpersonal relationships with the members of the Medical Staff, Medical Staff Leaders and Administrative and ancillary staff.
  • Promotes ongoing education.
  • Performs environmental surveillance to identify new opportunities.



  • Oversees 20+ credentialing and/or MSSD administrative FTEs
  • Trains, supervises, coaches and mentors MSSD staff
  • Recommends staffing levels for appropriate coverage
  • Oversee all aspects of the operations of the credentialing department of health care professionals ensuring appropriate credentialing verification services and privileging for hospital entities, medical staff and clients.
  • Monitors for compliance with regulatory and accreditation standards for applicable for medical staff within credentialing and privileging functions
  • Participates on hospital compliance teams and in regulatory/accreditation surveys as required
  • Enforces MSSD policies and procedures as applicable
  • Manages and supports the leadership meeting of the organized medical staff
  • Participates in and collaborates on medical staff and hospital committees as required
  • Collaborates with the quality department to fulfill requirements of established performance monitoring processes (i.e. focused on ongoing professional practice evaluation)
  • Supports and/or assists in implementing and monitoring credentialing software (CACTUS) as required
  • Reviews and refines MSSD departmental policies and procedures as needed

Knowledge, Skills and Ability Requirements:

  • 10+ years of experience directing medical staff services (staff of 20+)
  • Past experience as Director or Manager of Credentialing within in-patient setting of large hospital
  • Proficiency with Cactus credentialing software and database management


Send resume to:  Shema Patel at shema.patel@mssm.edu