Director of Medical Staff Services

Job Responsibilities:

Reporting to the Vice President of Medical Affairs (VPMA), this position is responsible for providing leadership, strategic direction, and operational oversight for all medical staff services at Johns Hopkins Howard County Medical Center. This role ensures compliance with regulatory requirements, accreditation standards, and medical staff bylaws while supporting the medical staff in credentialing, privileging, peer review, and governance activities. The Director works collaboratively with hospital leadership, department chairs, and physician leaders to enhance medical staff operations and promote a culture of quality and patient safety.

Role Accountabilities Include:

• Medical Staff Governance & Operations:

  • Oversee all functions of the Medical Staff Office, including credentialing, privileging, OPPE/FPPE, and peer review processes.

  • Ensure compliance with Joint Commission (TJC), Centers for Medicare & Medicaid Services (CMS), and other regulatory agencies.

  • Maintain and enforce medical staff bylaws, rules, and policies in collaboration with medical staff leadership.

  • Serve as a primary liaison between the medical staff, hospital administration, and regulatory bodies.

• Credentialing, Privileging, OPPE & FPPE:

  • In partnership with the Centralized Credentialing Office, direct the credentialing and privileging process, ensuring timely, accurate, and compliant processing of applications, reappointments, and privilege requests.

  • Oversee and implement Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) programs in collaboration with department chairs and quality teams.

  • Manage the credentialing database, ensuring data integrity and security of provider records.

  • Partner with compliance, quality, and legal teams to mitigate risks related to medical staff credentialing and privileging.

• Medical Staff Leadership & Support:

  • Provide administrative and strategic support to medical staff leadership, including the Medical Executive Committee (MEC), Credentials Committee, and other key governance bodies.

  • Assist in developing leadership training programs for medical staff officers and committee chairs.

  • Work with physician leaders to implement performance improvement initiatives and enhance medical staff engagement.

• Regulatory Compliance & Accreditation:

  • Coordinate medical staff documentation and audits to ensure continuous readiness for accreditation surveys.

  • Develop and maintain policies and procedures related to medical staff governance, credentialing, and performance evaluation.

• Medical Student, Resident & Fellow Rotators – Logistical Support:

  • Oversee and coordinate the onboarding and credentialing processes for medical students, residents, and fellows rotating at the hospital.

  • Ensure compliance with institutional policies, training requirements, and regulatory standards for medical trainees.

  • Collaborate with Graduate Medical Education (GME) offices, medical schools, and clinical departments to facilitate smooth rotations and training experiences.

  • Manage necessary documentation, including affiliation agreements, training verifications, and compliance tracking.

• Strategic & Operational Leadership:

  • Develop and implement efficiency-driven strategies to enhance medical staff operations and governance workflows.

  • Lead process improvement initiatives to streamline credentialing, privileging, and evaluation procedures.

  • Oversee the MSO budget, personnel, and technology systems to ensure optimal performance.

  • Support initiatives to improve medical staff satisfaction and engagement.

Qualifications:

• Bachelor’s degree required; Master’s in Healthcare Administration, Business Administration, or related field preferred.
• Certified Professional Medical Services Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS) preferred.
• Minimum of 5-7 years of experience in medical staff services, with at least 3 years in a leadership role.
• Extensive knowledge of medical staff governance, credentialing, privileging, OPPE/FPPE, and compliance with regulatory standards.
• Experience in medical education program coordination or supporting medical trainees is a plus.
• Strong leadership, communication, and relationship-building skills.
• Proven ability to collaborate with physician leadership and hospital administration

Salary Range: $140,000 per year - $175,000 per year. Compensation will be commensurate with equity and experience for roles of similar scope and responsibility.

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