Executive Director, Medical Staff Services

Job Description Summary

The Executive Director of Medical Staff Services (MSS) is the MUSCH system leader accountable for overseeing all functions and teams related to credentialing, privileging, peer review operations, and Focused Professional Practice Evaluation (FPPE) / Ongoing Professional Practice Evaluation (OPPE) operations. As such, the Executive Director will oversee the Medical Staff Office (MSO), Credentialing Verification Organization (CVO), and professional practices operations (PPO) functions. In this role, the Executive Director, MSS will be seen as the face of credentialing across the MUSC system and be the ultimate relationship manager for system executives for all credentialing, privileging, and peer review processes, concerns, and opportunities.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type​

Regular

Cost Center

CC004926 SYS - Credentialing and MSO

Pay Rate Type

Salary

Pay Grade

Health-38

Scheduled Weekly Hours

40

Work Shift

Job Description

Position Title: Executive Director, Medical Staff Services

Location: Charleston

Reports to: Chief Physician Executive, MUSC Health & MUSC Physicians

The Executive Director of Medical Staff Services (MSS) is the MUSCH system leader accountable for overseeing all functions and teams related to credentialing, privileging, peer review operations, and Focused Professional Practice Evaluation (FPPE) / Ongoing Professional Practice Evaluation (OPPE) operations. As such, the Executive Director will oversee the Medical Staff Office (MSO), Credentialing Verification Organization (CVO), and professional practices operations (PPO) functions. In this role, the Executive Director, MSS will be seen as the face of credentialing across the MUSC system and be the ultimate relationship manager for system executives for all credentialing, privileging, and peer review processes, concerns, and opportunities.

The Executive Director will serve as a key leader in developing policies, maintaining medical staff engagement, and ensuring high-quality medical staff support services across the system while working in close collaboration with Chief Medical Officers, Chief Quality Officers, the Medical Executive Committee (MEC), and other medical staff leaders (including department and committee chairs) to plan, organize, and direct the programs related to the Medical Staff Services Organization. The Executive Director will be accountable for MSS goals and objectives, including regular analysis and improvement of performance metrics.

The Executive Director will be based in Charleston and expected to travel to campuses across the system 3-4 times a month, or as needed.

Responsibilities

Credentialing & Privileging

• Accountable for ensuring the credentialing process for all physicians and providers is completed in a timely manner by the Medical Staff Office
• Oversees the relationship[s] with credentialing vendors, ensuring timely and accurate credentialing and re-credentialing of medical staff
• Serves as trusted advisor to regional Directors, Medical Staff Services and MUSC Health executive team for credentialing and privileging processes

Regulatory Compliance

• Accountable for effective Medical Staff Services operations, in compliance with accrediting bodies and regulatory agencies [including, but not limited to, The Joint Commission]
• Maintains up-to-date knowledge of relevant laws, regulations, and accreditation standards affective Medical Staff Services organization
• Participates in audits, surveys, and inspections related to Medical Staff Services, as required

Leadership & Management

• Develop, align, and provide strategic direction and leadership for Medical Staff Services across the CHS & RHN divisions, ensuring efficient management of medical staff credentialing, privileging, and governance functions across the MUSC Health system
• Oversee and partner with the Director, Medical Staff Servies for the Regional Health Network, the Director, Medical Staff Servies for Charleston Division, and Director, Professional Practices Operations on the development and operationalization of standard processes and policies for credentialing, privileging, peer review operations, FPPE / OPPE operations, and additional medical staff functions
• Foster a culture of collaboration, accountability, and continuous improvement across the Medical Staff Services Department across the MUSC Health system
• Develop, monitor, and take an active role in improvement of key performance indicators (KPIs) to assess overall performance of Medical Staff Services organization
• Implements and/or leads the implementation of corrective actions to address performance concerns and opportunities
• Oversees the development and implementation of improvement initiatives related to medical staff performance, credentialing processes, and professional evaluations
• Build and cultivate relationships with system Executives and leadership as a trusted partner to the medical staff
• Regularly engage with leadership across departments to address concerns, share updates on Medical Staff Services activities, and gather feedback to drive improvements in Medical Staff Services
• Partner with other executives and department heads to ensure medical staff services are integrated with broader system initiatives, promoting cohesion across functions.

System Standardization & Alignment

• Develop and drive initiatives to standardize medical staff-related functions across the system
• Ensure continuous improvement and process optimization across all Medical Staff Service functions
• Collaborate with Medical Staff Services Directors and system leadership to ensure alignment and consistency of practices
• Accountable for resource balancing and overall team management of the medical staff services team
• Maintains up-to-date knowledge of and engagement with related system functions [e.g., recruitment] to properly forecast credentialing demand and implements necessary actions to ensure consistent support of demand across the system
• Accountable for staying closely connected with the onboarding process to ensure credentialing activities are efficiently completed as a foundational step, including actively collaborating with the recruitment and onboarding teams to maintain alignment, ensure consistent integration, and provide required support to downstream activities impacted by MSS functions

Requirements (Education, Work Experience, Licensure, Registry and/or Certifications):

Education:

• Bachelor’s degree in Healthcare Administration, Business Administration, or a related field required
• Master’s degree in Healthcare Administration, Business Administration, or related field preferred

Experience:

• Minimum of 7-10 years of progressive leadership experience in Medical Staff Services or related healthcare management, with at least 5 years in a leadership role within a large healthcare system
• Demonstrated experience managing medical staff operations
• Extensive experience with privileging, credentialing, and peer review process
• Intimately familiar with latest regulatory requirements and accreditation standards (The Joint Commission, CMS, etc.)
• Proven track record overseeing peer review, Focused Professional Practice Evaluation (FPPE), and Ongoing Professional Practice Evaluation (OPPE) processes
• Experience collaborating with medical staff leadership, including Chief Medical Officers, Medical Executive Committees (MEC), and department and committee chairs
• Experience leading quality improvement initiatives and managing performance improvement for medical staff
• Credentialing software vendor management and partnership experience preferred

Skills

• Proven ability to lead, mentor, and manage dispersed, multidisciplinary teams across locations
• Strong interpersonal, communication, and leadership skills with the ability to build and maintain relationships at all levels of the organization, especially at the executive level
• Ability to manage multiple priorities in a fast-paced environment
• Ability to manage complex projects, prioritize tasks, and meet deadlines in a dynamic healthcare environment
• Strategic thinking and problem-solving skills, with the ability to design and implement initiatives to centralize and streamline Medical Staff Services
• Proficiency in relevant software systems (e.g., credentialing software, MS Office, etc.)
• High level of integrity and confidentiality, particularly regarding peer review processes and provider performance evaluations

Senior Director for a department or a business unit. Manages two or more professional and support staff including subordinate managers. More discretion and greater financial authority than lower management levels. Directs the analysis, planning, implementation, and expenditures and budget tracking of major operational projects or initiatives. Provides recommendations to the leaders throughout the organization. Leads in developing strategies and implementation plans to improve and standardize all aspects of operations. Works independently and in collaboration with leadership to support the budget process and meeting key operational goals. Collaborates with leaders to establish operating procedures, enhance clinical and non-clinical workflows, increase productivity, and improve overall quality outcomes and operational efficiencies within a variety of delivery settings. Establishes department policies and procedures. This role will serve as the primary liaison for the department. Manages and influences relationships with senior management team, administrators, functional area managers and staff to achieve best in practice performance and business results.

Additional Job Description

Education: Bachelor's Degree or Equivalent Work Experience: 10 years progressive work experience and 5 years management experience

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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