This position effectively creates the Medical Staff’s strategic, operational, programmatic and other policies, Bylaws, Rules & Regulations related to achieving the Mission and Vision of the organization.  Serves as an internal resource to the medical staff and hospital management with respect to compliance with the Joint Commission/CDHS/CMS (Medicare Conditions of Participation) and medical staff related activities, including standards related to medical staff participation in organization-wide performance improvement and leadership.  Monitors the budget, researches variances and identifies opportunities to reduce costs.

• Complete ongoing and annual review of all Medical Staff Bylaws, Rules & Regulations and Policies & Procedures and development of same when necessary/required by changes in state/federal laws and/or modification of physician/hospital practices.
• Coordination, development, implementation, composition and continuous maintenance of a comprehensive system by which the Medical Staff and Governing Body can be assured all members of the medical staff undergo continued surveillance of the professional performance of each individual within each department who has delineated clinical privileges.
• Assessment, redesign, implementation of the Department of Medical Staff Services systems, performance and assessment of employee educational needs.
• Coordination, development, implementation, composition and continuous maintenance of a comprehensive system by which the Medical Staff and Governing Body can be assured all members of the medical staff undergo continued surveillance of the professional performance of each individual within each department who has delineated clinical privileges.
• Administer/coordinate both formal and informal physician problem resolution processes, inclusive of formal Fair Hearing for physicians and grievance procedures for Allied Health Professionals.

• Bachelor’s Degree in Business, Hospital Administration, or related field, or equivalent experience.
• Minimum of five (5) years of progressive management experience within a medical staff acute care hospital.
• Ability to perform effectively as a medical staff resources generalist, with demonstrated competency in such functional areas as physician and Allied Health Practitioner credentialing/re-credentialing, physician relations, Medical Staff Quality Improvement processes, broad based knowledge of Joint Commission standards and other applicable federal, state and local regulatory agency requirements which affect the medical staff and hospital. 
• Excellent verbal and written communication skills.
• To effectively and knowledgeably perform this job function, Certified Professional Medical Services Management (CPMSM) is required and Certified Provider Credentials Services (CPCS) is preferred