Executive Director Medical Affairs

Overview

Feb 03, 2026

The Executive Director of Medical Affairs has responsibility for directing and coordinating the system wide daily operations of the Medical Staff Services and Medical Staff Quality Departments.

• Leads system wide accreditation activities by maintaining an extensive knowledge-base of Federal/State statues and regulatory guidelines pertaining tthe Medical, Dental and Advanced Practice Provider (APP).
• System wide medical staff exceeds over 2000 providers which requires exceptional communication and organizational skills. Provides system wide oversight of the credentialing process for Medical, Dental, APP staff as specified in the Medical and Dental Staff Bylaws, Rules and Regulations, in collaboration with Medical Staff leadership, Hospital Administration, Board of Trustees, and Federal/State statues and regulatory guidelines.
• Oversees and understands Medical Staff bylaws and organizes changes to the bylaws as recommended by the Medical Staff(s).
• Provides system wide oversight of the performance improvement/peer review functions of the Medical, Dental, and APP staff, ensuring findings are appropriately reviewed, communicated and documented as specified in the Medical Staff Bylaws, Rules & Regulations, in collaboration with Medical and Dental Staff leadership and Federal/State statues and regulatory guidelines.
• Provides oversight of system wide Medical Affairs cost center budgets including recommendations, projections, monitoring and reconciling of expenditures, and identification of cost savings.
• Translates organizational strategic planning initiatives into effective system wide departmental goals and objectives.
• Provides oversight of the development and implementation of system wide policies and procedures that guide and support the provision of Medical, Dental and APP services.
• Serves as a system wide resource to the Medical and Dental Staff, hospital staff, and organizational leadership regarding all aspects of medical staff matters including credentialing standards, peer review, required interventions concerning counseling and discipline, etc

• Masters, Required in Nursing, Healthcare Administration or Business

• Required:
  
  Minimum 5 years in Medical Staff Services including expertise in peer review process and familiarity with "just culture" as it relates to Peer Review and provider behavior.
• Minimum 5 years in management; prior experience with regulatory standards, compliance and audit.
• Preferred:
  Expertise in physician and ancillary provider privileging and credentialing.
• Expertise and knowledge of CMS standards related to privileging and credentialing of providers

• REQUIRED Current licensure in Nursing or other clinical license if applicable; CPMSM and CPCS required.
• PREFERRED Drivers License | Valid Drivers License CPHQ preferred.

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