Director of Medical Staff Services

Title: Medical Staff Director

Location: Laguna Hills, CA

Department: Medical Staff Services

Status: Full-time

Shift: Day

Pay Range*: $139,859-$192,327/annually

Memorial Care is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups – consisting of over 200 sites of care, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your personal contributions are integral to Memorial Care's recognition as a market leader and innovator in value-based and other care models.

Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork.

This position is a management position with accountability for the daily operations and evaluations of the Medical Staff Services at Saddleback Medical Center. This position effectively creates the medical staff’s operational, programmatic and other policies, bylaws, and rules and regulations related to achieving the Mission and Vision of Saddleback and MHS. Directs the Medical Staff leaders in ensuring compliance with regulatory, accreditation, and hospital bylaws while supporting the medical staff in proper credentialing, privileging, governance, and quality/performance improvement activities/issues.

Maintains the CME Program. Director serves as a key liaison between the medical staff, hospital administration, and external regulatory bodies. Develops and monitors the Medical Staff budget. Researches variances and identifies opportunities to reduce costs.

• Accountable for the development, direction, planning and evaluation of the Medical Staff Services s position effectively creates the medical staff’s strategic, operational, programmatic and other policies, bylaws and rules and regulations related to achieving the mission and vision of Saddleback and MHS.
• This includes leadership and management, compliance and accreditation, medical staff governance, credentialing and privileging, and quality and performance improvement.
• Oversee daily operations of the Medical Staff Office, including credentialing, privileging, and reappointment processes.
• Lead and mentor a team of medical staff professionals, ensuring high performance and engagement.
• Develop and implement departmental policies and procedures aligned with hospital bylaws and regulatory standards.
• Develop and ensure adherence to departmental budget and Medical Executive Committee budget.
• Ensure compliance with Joint Commission or accreditation body (i.e., DNV, etc.), CMS, California Department of Public Health, and other regulatory requirements.
• Complete ongoing review of all medical staff manuals as required by changes in state and federal laws, and/or modifications of physician/hospital practices.
• Maintain accurate and timely documentation for audits and surveys.
• Monitor changes in laws and regulations affecting medical staff governance and credentialing.
• Support medical staff leadership in organizing meetings, elections, educational and committee activities.
• Advise on interpretation and application of medical staff bylaws, rules, and regulations.
• Facilitate communication between medical staff and hospital administration.
• Administer and coordinate both formal and informal physical problem resolution processes, inclusive of formal fair hearing procedures and the Allied Health Professional grievance process.
• Oversee initial and reappointment credentialing processes, ensuring accuracy and timeliness.
• Manage privileging and scope of practice verification for all practitioners.
• Utilize credentialing software and maintain secure provider records.
• Collaborate with Quality and Risk Management teams on peer review and performance improvement initiatives.
• Track and report key metrics related to credentialing and…