Director, Medical Staff Office

When you join the growing BILH team youre not just taking a job youre making a difference in peoples lives.

The System Medical Staff Office (MSO) Director provides strategic and operational leadership for Medical Staff Office operations across the Beth Israel Lahey Health (BILH) system overseeing 11 hospital-based departments. This role is responsible for ensuring consistent compliant and high-quality medical staff services in support of credentialing privileging governance regulatory readiness and professional practice evaluation. The Director oversees personnel management departmental budgets operational workflows quality improvement initiatives policy alignment and performance metrics. The ideal candidate is a collaborative and results-driven leader with deep expertise in medical staff services accreditation standards and health system operations.
The Director maintains a strong business partnership with the System Director of the Credentials Verification Office (CVO) to ensure seamless coordination between centralized credentialing functions and hospital-based medical staff operations. Together they collaborate on aligned workflows shared metrics and regulatory compliance efforts that support a unified system-wide approach to provider credentialing and governance.

Job Description:

Essential Duties & Responsibilities including but not limited to:

Leadership & Supervision:

• Provide system-level direction and supervision for Medical Staff Office managers and personnel across 11 hospitals.
• Develop and implement standardized policies procedures and workflows to ensure consistency and regulatory compliance across all sites.
• Foster a culture of accountability service excellence and continuous improvement.
• Conduct performance evaluations support professional development and foster a culture of accountability and continuous improvement.
• Provide back-up support to MSO leads as needed to maintain continuity of operations.

MSO Operations & Credentialing Oversight:

• Oversee and support all aspects of medical staff office operations and credential file review and approval process.
• Ensure timely accurate and compliant credentialing and privileging processes in collaboration with the Credentials Verification Office (CVO).
• Oversee management of provider expirables and initial and reappointment harmonization cycles across the system.

Governance & Committee Support:

• Support medical staff governance structures and ensure consistent processes for medical staff elections officer appointments and membership categories.
• Provide administrative and operational support for medical staff committees (e.g. Credentials Committee MEC Peer Review Bylaws Committees).
• Oversee the maintenance of accurate documentation such as committee meeting minutes reports and committee actions.

Compliance Quality and Regulatory Readiness:

• Monitor and maintain compliance to applicable regulatory standards (NCQA Joint Commission and CMS) as well as applicable state and federal regulations.
• Participate in the review of credentialing delegation agreements between the hospitals and insurance plans.
• Lead preparation for regulatory surveys and audits related to medical staff functions
• Maintain current knowledge of applicable medical staff bylaws rules and regulations and associated medical staff policies and procedures.
• Coordinate quality assurance activities and support medical staff offices in preparation for surveys and audits.
• Oversee FPPE/OPPE programs in collaboration with quality and department chairs ensuring ongoing professional practice evaluation is tracked reported and acted upon.
• Partner with system and site leadership to ensure provider quality concerns are escalated and addressed through appropriate channels.

Performance Monitoring & Metrics:

• Monitor team productivity and file turnaround times ensuring performance aligns with established department standards and service expectations.
• Develop maintain and report on departmental metrics and performance goals.
• Monitor hospital and provider satisfaction and work collaboratively with CVO to address service issues.

Data & Systems Management:

• Oversee database entries to ensure accuracy completeness and consistency of provider records.
• Ensure the maintenance of electronic files in compliance with system standards and accreditation requirements.
• Assist with the development optimization and integration of the credentialing software system (e.g. MD-Staff) including workflows reporting and automation.
• Oversee the development or revision of MSO and credentialing-related forms and documentation tools.

Budget & Financial Oversight:

• Participate in the development of the annual departmental budget.
• Support oversight of purchasing activities and collection of credentialing fees where applicable.

Policy & Bylaws Management:

• Assist in the development review revision and implementation of system-wide medical staff policies and procedures.
• Lead harmonization of medical staff bylaws across the system in collaboration with legal counsel compliance and hospital leadership.
• Ensure that policy updates are communicated tracked and documented in accordance with governance structures.

Other Responsibilities:

• Represent Medical Staff Office operations in system committees task forces and integration initiatives.
• Support leadership reporting project implementation and strategic planning related to credentialing and provider lifecycle management.
• Perform other duties as assigned.

Minimum Qualifications:

Education:

• Bachelors degree in healthcare administration or a related field strongly preferred.
• An equivalent combination of education and progressively responsible experience may be considered in lieu of a degree.

Licensure Certification & Registration:

• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) required.
• Equivalent experience in a senior medical staff or credentialing leadership role project management or HR may be considered in lieu of certification subject to approval.

Experience:

• Minimum of 5 years of progressively responsible experience in Medical Staff Services Credentialing project management or HR including 2 years in a leadership or multi-site management role.
• Demonstrated knowledge of regulatory standards (Joint Commission NCQA CMS) and state/federal regulatory requirements.
• Experience supporting medical staff governance bylaws development and credentialing/privileging processes in a hospital or system setting is preferred
• Demonstrated experience managing budgets staff development and operational performance metrics.

Skills Knowledge & Abilities:

• Exceptional leadership collaboration and team-building skills.
• Strong organizational and project management abilities with the capacity to oversee complex system-wide initiatives.
• Excellent verbal and written communication skills with experience supporting medical staff leaders and executive teams.
• High degree of professionalism discretion and ability to manage sensitive issues.
• Proficient in credentialing systems (e.g. MD-Staff) Microsoft Office Suite and data reporting tools.

Organizational Requirements:

1. Maintain strict adherence to the BILH Confidentiality policy.
2. Incorporate BILH Standards of Behavior and Guiding Principles into daily activities.
3. Comply with all Departmental Policies.
4. Comply with behavioral expectations of BILH.
5. Maintain courteous and effective interactions with colleagues providers and BILH leadership.
6. Demonstrate an understanding of the job description performance expectations and competency assessment.
7. Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to BILH customer service standards.
8. Participate in departmental and/or interdepartmental quality improvement activities.
9. Participate in and successfully completes Mandatory Education.
10. Perform all other duties as needed or directed to meet the needs of the department

Key Relationships:

• Department Executive Director Reports directly to and collaborates with the Executive Director of System Provider Credentialing and Medical Staff Services to implement strategic goals standardize operations and ensure alignment with system priorities and regulatory standards.
• System CVO Director Maintains a strong business partnership to ensure coordination between Medical Staff Office operations and centralized credentialing functions. Together they align file workflows regulatory readiness and shared responsibilities for provider lifecycle management and compliance.
• System CVO Staff Works in coordination with credentialing specialists and analysts to maintain seamless processing of provider files and reappointment cycles and to support regulatory preparedness.
• Medical Staff Office (MSO) Staff Provides direct leadership and oversight to MSO teams at all BILH hospitals ensuring consistent application of policies staff development performance tracking and operational excellence.
• Hospital Chief Medical Officers (CMOs) Serves as a key liaison to CMOs supporting their leadership of medical staff governance credentialing decisions and quality improvement activities.
• Hospital Chief Executive Officers (CEOs) Engages with site executives to align MSO operations with hospital priorities address concerns related to medical staff support and ensure system standards are consistently upheld.
• Department Medical Director Partners with the medical leadership of the department to implement strategic initiatives address provider performance concerns and ensure medical staff processes are clinically aligned and support quality care delivery.

As a health care organization we have a responsibility to do everything in our power to care for and protect our patients our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement.

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