Our pre-employment assessment is changing as of 10/29. If you are applying to newly posted positions, you will need to take the revised assessment.

Job Details

Director, Medical Staff Administration

Requisition #: 186025
Location: Johns Hopkins Hospital/Johns Hopkins Health System, Baltimore, MD 21201
Category: Leadership
Work Shift: Day Shift
Work Week: Full Time (40 hours)
Weekend Work Required: No
Date Posted: May 20, 2019

The Johns Hopkins Hospital (JHH) is a 1,192 beds teaching hospital and biomedical research facility of the Johns Hopkins School of Medicine, located in Baltimore, Maryland, U.S. Johns Hopkins Hospital and its school of medicine are considered to be the founding institutions of modern American medicine and the birthplace of numerous famous medical traditions including rounds, residents and house staff. Many medical specialties were formed at the hospital including neurosurgery, by Dr. Harvey Cushing; cardiac surgery by Dr. Alfred Blalock; and child psychiatry, by Dr. Leo Kanner. Johns Hopkins Hospital is regarded among the best hospitals and medical institutions of the world.

Position Summary:

Provides leadership and operational oversight of the Medical Staff Administration office. Directs and organizes administrative activities for the Medical Staff, including credentialing, privileging, focused and ongoing physician performance evaluations. Also responsible for achieving regulatory compliance and the management of various Medical Staff leadership meetings. Serves as Registrar of JHH Medical Staff / credentialed staff. Reviews maintain and interpret the JHH Medical Staff Bylaws. Oversees the information system for credentialed staff as it pertains to JHH. Oversees the Hospital aspects of medical residency/fellowship programs, including review and approval of related expenditures by JHH. Collaborates with the Senior Director of the JHHS Central Credentialing Office (CCO) to establish credentialing policies and maintain efficient flow of verifications. Works collaboratively with the Directors of medical staff services at other JHHS hospitals to establish common practices and address regulatory standards.

Education& Experience:

  1. Requires a Bachelor’s degree (medical or business field preferred), master’s degree preferred. Clinical education (e.g. registered nurse) is desired but not required.
  2. Five years in a clinical or administrative field, with medical staff administration and/or regulatory compliance experience preferred
  3. Certified Professional in Medical Services Management (CPMSM), or, Certified Provider Credentialing Specialist (CPCS) desirable or willing to obtain.
  4. Certified Professional in Healthcare Quality (CPHQ) Preferred
  5. Thorough knowledge of: credentialing, privileging, accreditation standards and federal and local regulatory requirements related to areas of responsibility as well as the Hospital in general (esp. the Joint Commission and the Accreditation Council of Graduate Medical Education); medical staff governance;, structure and operating policies of JHH and JHHS; risk management principles; OPPE and FPPE processes.
  6. Proven organizational, project management, financial systems, and supervisory skills are essential.
  7. Highly effective oral, written and interpersonal skills.

Duties & Responsibilities:

  1. Develops and approves Medical Staff Administration budget. In conjunction with JHU, helps to develop a budget for House Staff; approves expenditures from General Hospital funds for House Staff.
  2. Develops and approves policies for the department. Develops policies for Medical Staff and recommends them to Medical Staff leadership. Editorial authority for Hospital policies in the Interdisciplinary Clinical Practice Manual and select other policies. Develops and approves policies for the department. Develops policies for Medical Staff and recommends them to Medical Staff leadership. Editorial authority for Hospital policies in the Interdisciplinary Clinical Practice Manual and select other policies.
  3. Directs all staff in Medical Staff Administration. Leads various JHHS medical staff-related initiatives.
  4. Provided guidance to other JHHS entities in matters pertaining to credentialing, house staff, and general medical staff issues.
  5. Uses critical thinking, scientific inquiry, and other high-level processes to analyze complex problems. Uses a multidimensional knowledge base to seek ideal solutions.
  6. Uses complex data from medical staff systems, quality improvement initiatives, and other sources to direct ongoing work of the department and resolve departmental and hospital problems.
  7. Directs JHH credentialing services
  8. Collaborate with Johns Hopkins Health System CCO and other entities to assure complete and properly-prepared primary source verifications for applicants to Medical and Affiliate Staffs as well as the reappointment of current staff,
  9. Directs credentialing of Resident Staff (interns, residents, and clinical fellows)
  10. Collaborates with Johns Hopkins University (JHU) staff to develop policies for management of house staff roles, issues, expectations.
  11. Organizes and oversees House Staff Orientation in collaboration with JHU.
  12. Participates in the development of JHH general budget for House staff matters.
  13. Plans and organizes MSA operations to achieve compliance with regulatory standards and requirements. The Joint Commission (TJC), the National Committee on Quality Assurance (NCQA) and the Accreditation Council for Graduate Medical Education (ACGME) are the predominant agencies of focus.
  14. Professional Practice Evaluation (PPE) (TJC)

Johns Hopkins Health System and its affiliates are drug-free workplace employers.

Johns Hopkins Health System and its affiliates are an Equal Opportunity / Affirmative Action employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.


Learn More About
Johns Hopkins Medicine.