Position Summary

The Medical Staff Administrative / Credentialing Officer is responsible for managing the hospital's medical staff services and credentialing program. This role ensures compliance with regulatory, accreditation, and hospital bylaws requirements while supporting medical staff leadership in governance, credentialing, privileging, and peer review. The officer serves as the liaison between hospital administration, medical staff leadership, and clinical departments to maintain an effective credentialing and privileging process

Essential Duties and Responsibilities

• Medical Staff Administration * Serve as the primary resource and liaison for the organized Medical Staff and its committees (e.g., Medical Executive Committee, Credentials Committee, Peer Review). * Prepare agendas, minutes, and follow-up actions for medical staff committees and meetings. * Ensure adherence to hospital Medical Staff Bylaws, Rules & Regulations, and Policies. * Support the medical staff in governance, elections, and communications. * Maintain accurate medical staff rosters, call schedules, and directories.
• Credentialing & Privileging * Coordinate all aspects of credentialing, privileging, and recredentialing for medical staff and allied health professionals in accordance with hospital bylaws, CIHQ/Joint Commission, CMS, and state regulatory requirements. * Verify credentials including licensure, education, training, board certification, work history, references, malpractice history, NPDB, OIG/SAM, and other primary source verifications. * Track expirables (licenses, DEA, certifications, insurance, etc.) and maintain compliance. * Manage and maintain credentialing database (e.g., MD-Staff, Echo, or internal system). * Work collaboratively with department chairs and clinical leadership to facilitate privilege delineation and competency review.
• Compliance & Quality Support * Ensure compliance with CIHQ/Joint Commission, CMS Conditions of Participation, and state regulatory standards related to medical staff services and credentialing. * Support peer review, quality monitoring, and FPPE/OPPE processes. * Prepare credentialing and privileging files for survey readiness and audits. * Provide reports to administration, quality council, and governing body as needed.

Knowledge, Skills, and Abilities

• In-depth knowledge of medical staff organization, credentialing, privileging, and regulatory requirements.
• Strong organizational and time-management skills with attention to detail.
• Excellent written and verbal communication skills.
• Proficiency with credentialing software (e.g., MD-Staff, Echo) and Microsoft Office Suite.
• Ability to handle sensitive and confidential information with discretion.
• Strong interpersonal skills with physicians, hospital leadership, and staff.

Education & Experience

• Bachelor's degree preferred (Healthcare Administration, Business, Nursing, or related field).
• Minimum 3–5 years of experience in medical staff services and credentialing required.
• Experience in a hospital setting with CIHQ/Joint Commission accreditation preferred.
• Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM) strongly preferred or obtained within 2 years of hire.