Director of Medical Staff Services

• The Director of Medical Staff Services provides strategic and operational leadership for Medical Staff Services, credentialing and privileging operations, provider lifecycle management, provider data governance, and medical staff governance activities for Lake Charles Memorial Health System.

• This position serves as the organization's subject matter expert for medical staff administration, credentialing and privileging, practitioner regulatory compliance, provider data integrity, provider lifecycle management, and medical staff governance. The Director acts as a key liaison between Hospital Administration, Medical Staff Leadership, Department Chairs, Medical Directors, employed and independent practitioners, and regulatory and accrediting organizations.

• The Director is responsible for establishing and maintaining systems that support regulatory compliance, practitioner competency oversight, provider data integrity, operational efficiency, and effective medical staff governance. The position ensures compliance with Medical Staff Bylaws, Rules and Regulations, organizational policies, Centers for Medicare & Medicaid Services (CMS) Conditions of Participation, DNV Healthcare Accreditation Requirements, and other applicable federal and state regulations.

• Direct and oversee all Medical Staff Services operations.
• Serve as administrative liaison to Medical Staff Officers, Medical Executive Committee, Credentials Committee, Department Chairs, Medical Directors, and hospital executive leadership.
• Provide leadership and consultation regarding Medical Staff Bylaws, Rules and Regulations, policies, credentialing standards, privileging requirements, and regulatory compliance.
• Coordinate Medical Staff governance activities, including Medical Executive Committee, Credentials Committee, department meetings, special committees, and leadership councils.
• Ensure preparation and maintenance of agendas, supporting documentation, official minutes, correspondence, recommendations, and follow-up actions.
• Facilitate committee appointments, leadership transitions, elections, and governance initiatives.
• Develop, maintain, and recommend revisions to Medical Staff governing documents.
• Advise Medical Staff leaders and administration regarding changes in regulatory, accreditation, and industry requirements.

• Direct, maintain and oversee all aspects of practitioner credentialing, reappointment, privileging, focused professional practice evaluation (FPPE), ongoing professional practice evaluation (OPPE), and competency assessment processes.
• Ensure primary source verification activities are conducted in accordance with accreditation, regulatory, and organizational requirements.
• Ensure timely processing of initial applications, reappointments, privilege requests, and provider status changes.
• Develop and maintain credentialing policies, procedures, applications, forms, and privilege delineation criteria.
• Oversee management of licensure, board certification, DEA registration, professional liability insurance, continuing education requirements, and all other expirable credentials.
• Collaborate with Quality, Risk Management, Medical Staff Leadership, and hospital administration regarding peer review, practitioner performance evaluation, and quality improvement activities.

• Collaborate with Physician Recruitment, Human Resources, Legal, Compliance, Information Technology, Quality, and operational leaders to ensure efficient practitioner onboarding and integration.
• Establish and maintain standardized onboarding processes to ensure practitioners are appropriately credentialed, privileged, and operationally prepared to provide patient care services.
• Oversee practitioner demographic, training, licensure, certification, competency, and privilege information throughout the provider lifecycle.
• Ensure timely communication of provider appointments, privileges, restrictions, expirables, and status changes to applicable departments and stakeholders.
• Maintain processes that support practitioner movement across facilities, departments, and service lines within the health system.
• Monitor lifecycle performance indicators related to onboarding timeliness, reappointment completion, practitioner readiness, and compliance.
• Support physician recruitment and retention initiatives through efficient and customer-focused Medical Staff Services operations.

• Lead organizational readiness efforts for DNV, CMS, and other Medical Staff-related regulatory and accreditation reviews.
• Ensure ongoing compliance with Medical Staff Bylaws, organizational policies, accreditation standards, and Conditions of Participation.
• Coordinate survey preparation, documentation reviews, tracers, corrective action plans, and responses to findings.
• Monitor regulatory changes and implement required operational and policy updates.
• Provide education and guidance to Medical Staff leaders and organizational leadership regarding compliance requirements.

• Develop, administer, and monitor departmental budgets.
• Evaluate staffing models, workflow effectiveness, operational efficiencies, and technology solutions.
• Lead continuous process improvement initiatives designed to enhance service, compliance, and operational effectiveness.
• Foster a culture of accountability, collaboration, professionalism, and service excellence.

• Serve as the organizational expert regarding Medical Staff Services, credentialing, privileging, provider lifecycle management, and provider data governance.
• Educate Medical Staff leaders, department chairs, administrators, physicians, advanced practice providers, and department managers regarding Medical Staff governance and compliance requirements.
• Support physician recruitment, onboarding, orientation, leadership development, and governance education initiatives.
• Maintain professional competency through continuing education and participation in relevant state and national Medical Staff Services organizations.

• Required: Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, Nursing, Public Health, or a related field.
• Preferred: Master's degree in Healthcare Administration (MHA), Business Administration (MBA), Nursing, Public Health, or related field.

• Required: Seven (7) years of progressive leadership experience in Medical Staff Services, credentialing, privileging, provider data management, regulatory compliance, or related healthcare operations.
• Required: Multi-hospital or integrated health system experience.
• Preferred: Experience with credentialing software and provider information management systems.
• Preferred: Experience supporting hospital accreditation and regulatory surveys.

• Current CPMSM or CPCS certification preferred. Equivalent experience in medical staff services, credentialing, privileging, or provider enrollment may be considered. Incumbent must successfully obtain CPMSM or CPCS certification within allowable timeframe set by Chief Medical Officer.
• Certification must be maintained in good standing.

• Expert knowledge of Medical Staff governance, credentialing, privileging, peer review, and practitioner competency assessment.
• Advanced knowledge of CMS Conditions of Participation, DNV requirements, and healthcare accreditation standards.
• Comprehensive understanding of provider lifecycle management and provider data governance principles.
• Strong knowledge of credentialing software, provider databases, reporting tools, and Microsoft Office applications.
• Excellent leadership, communication, organizational, analytical, and problem-solving skills.
• Ability to establish effective working relationships with physicians, executives, regulatory agencies, and multidisciplinary teams.
• Demonstrated ability to manage multiple priorities while maintaining accuracy and compliance.
• Strong written communication and policy development skills.

• Primarily sedentary work performed in an office environment.
• Frequent use of computers and office equipment.
• Ability to sit for extended periods with occasional standing, walking, bending, reaching, and lifting of office materials.
• Ability to attend meetings, surveys, conferences, and educational programs as required..

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