Medical Staff Services Manager

Overview

Position:
Medical Staff Services Manager

This is a fulltime, salary exempt position.

Position is in office.

At Good Shepherd Health Care System, we put "Patients First. Always." We are committed to bringing state‑of‑the‑art care closer to home and providing exceptional care to our community.

Why Choose Good Shepherd?

• Independent & Financially Stable organization
• Top‑tier benefits package offering 100% employer‑paid healthcare premiums (medical, dental, and vision) for both employees and their families.
• State‑of‑the‑Art Facilities & Services
• Supportive Administration & Culture
• Thriving, Growing Region supporting outdoor lifestyle & adventure.

Good Shepherd Health Care System remains one of the largest employers in the area and plays a pivotal role in the region's continued growth.

The Medical Staff Services Manager is responsible for the management and oversight of all Medical Staff Services functions for Good Shepherd Health Care System. This role ensures compliance with Medical Staff Bylaws, Rules and Regulations, accreditation standards, and applicable federal, state, and local regulations related to credentialing, privileging, peer review, and medical staff governance.

The Medical Staff Services Manager serves as a primary liaison between the Medical Staff, hospital administration, governing body, and regulatory agencies. This position supervises the Credentialing Coordinator and ensures accurate, timely, and compliant credentialing and recredentialing processes for all physicians and advanced practice providers.

• Manages the daily operations of the Medical Staff Services Department in accordance with Medical Staff Bylaws, Rules and Regulations, hospital policies, and accreditation standards.
• Acts as executive secretary to elected Medical Staff officers and committee chairs.
• Prepares agendas, attends meetings, records minutes, and ensures follow‑up for the Medical Executive Committee, Credentials Committee, and other medical staff committees as assigned.
• Manages the flow of information and recommendations from medical staff committees through the Medical Executive Committee to the Board of Trustees.
• Develops, maintains, and coordinates review of medical staff governance documents, including bylaws, rules and regulations, and related manuals.
• Serves as a resource to Medical Staff leadership regarding interpretation and application of bylaws and policies.

• Oversees credentialing, recredentialing, and privileging processes for all physicians and advanced practice providers.
• Supervises the Credentialing Coordinator, including work prioritization, training, performance oversight, and quality review.
• Ensures credentialing files are complete, accurate, current, and compliant with CMS, DNV/NIAHO, CAH, and state regulatory requirements.
• Co‑ordinates review and evaluation of applications for appointment, reappointment, and clinical privileges through appropriate medical staff leadership and committees.
• Ensures timely tracking and management of expiring licenses, certifications, privileges, and other required credentials.
• Maintains practitioner data within credentialing and hospital information systems to accurately reflect current status and governing body actions.

• Serves as the subject matter expert for medical staff‑related accreditation and regulatory requirements.
• Co‑ordinates preparation for and participation in accreditation and regulatory surveys (e.g., DNV/NIAHO, CMS, CAH).

• Ensures Medical Staff Services operations remain survey‑ready at all times.
• Facilitates the development and implementation of corrective action plans related to medical staff services findings or deficiencies.
• Maintains policies and procedures to support ongoing compliance with applicable laws and regulations.

• Co‑ordinates with Quality, Risk Management, and Medical Staff leadership to support FPPE, OPPE, and peer review processes.
• Ensures appropriate documentation, confidentiality, and compliance with peer review and…