| Location | Fremont, California |
Position Summary:
The Director of Medical Staff Services provides leadership, operational oversight, and direction for Medical Staff Services to ensure effective medical staff governance and compliance with applicable regulatory, accreditation, and organizational requirements. The position serves as an educational and consultative resource regarding credentialing, privileging, and medical staff governance for physicians and Advanced Practice Providers (APPs), while working collaboratively with the Chief Medical Officer, other Medical Staff, and Hospital Leadership. This role maintains accountability for the execution of core functions, while aligning with and supporting the broader vision and direction of the Organization. The Director directly supervises the Medical Staff Services team and is accountable for the department’s operating budget and Medical Staff funds.
Education: Preferred
Bachelor’s degree in healthcare administration or related field; extensive equivalent experience may be considered in lieu of degree
Certification: Required (or obtained within 12 months of hire)
Certified Professional Medical Services Management (CPMSM) by the National Association Medical Staff Services (NAMSS); Certified Provider Credentialing Specialist (CPCS) preferred in addition
Work Experience: Required
A minimum of five years of progressive leadership experience in Medical Staff Services at the Manager or Director level in an acute care hospital setting, and seven to 10 years of experience in medical staff credentialing and privileging. Additional experience with delegated credentialing, NCQA standards, and multi-site or health-system environments is preferred.
Skills/computer/specific technical: Required
Proficiency with credentialing and provider data management platforms (CredentialStream preferred), quality/peer review data tools such as Midas, and Microsoft Office (Word, Excel, PowerPoint, Outlook)
Excellent written and verbal communication skills
Excellent interpersonal skills and experience in a diverse professional setting
Knowledge of medical terminology
Knowledge of medical staff continuing medical education programs
Strong organizational and problem-solving skills to manage complex staff processes
Ability to analyze credentialing, privileging, and peer review data and prepare clear reports for the MEC, Board of Directors, and Hospital Leadership.
Other qualifications: Required
Extensive expertise in credentialing and privileging in an acute care setting
Excellent skills in meeting management of the medical staff (includes agenda prep, scheduling, and minute-taking)
Expert knowledge of accreditation and regulatory requirements including The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, California Department of Public Health (CDPH) requirements, California Code of Regulations (Title 22), California Health and Safety Code and California Business and Professions Codes of relevant credentialed providers.
Comprehensive understanding of the confidential peer review protections as provided by California Evidence Code 1157, including process for OPPE, FPPE, and proctoring.
Working knowledge of California-specific medical staff reporting and verification obligations, including Business and Professions Code Section 805 reporting, National Practitioner Data Bank (NPDB) querying and reporting, Health Care Quality Improvement Act (HCQIA) peer review requirements, California Evidence Code 1157, OIG/SAM and Medicaid exclusion screening, and verification with the Medical Board of California, Osteopathic Medical Board of California and other applicable licensing boards
Knowledge of NCQA credentialing standards and delegated credentialing agreements, and CMS/The Joint Commission requirements for telemedicine credentialing by proxy
Experience credentialing and privileging Advanced Practice Providers, including Interdisciplinary Practice Committee (IDPC) processes required under Title 22.
Experience in providing strategic guidance on Medical Staff Bylaws, Rules & Regulations, policies, and other governance processes
Ability to manage competing priorities and meet critical deadlines
Experience in management of departmental operational budget
Demonstrated experience directly supervising staff, including hiring, performance management, coaching and staff development
Reports to:
Chief Executive Officer
Direct reports: Medical Staff Services Team
Key working relationships: Chief Medical Officer; Chief of Staff and Medical Staff Officers; Medical Executive Committee (MEC); Quality/Risk Management; Legal Counsel
Budget accountability: Medical Staff Services operating budget and Medical Staff funds (dues, stipends)
Salary Range: Min: $156,000 Mid: $195,000 Max: $234,000
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