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Job Number: 20094384812
Position Title: Medical Staff Office Manager
Location: Springfield, GA

Under the general direction of the Chief Support Services, the Medical Staff Office Manager will coordinate and manage administrative activities and processes of the Medical Staff and Allied Health credentialing in accordance with CMS and TJC, federal, state, and local guidelines, organizational and departmental policies and procedures. Communicates with medical staff, other departments, and outside agencies while maintaining confidentiality.  Monitoring and tracking Peer Reviews. (OPPE/FPPE). Coordinates and documents monthly committee meetings.  Position requires self-motivation, creativity, and capabilities to function in a semi-autonomous role within a fast pace and dynamic environment. 

Required Skills:
  1. Plans, organizes and directs the day-to-day operations of Medical Staff Services Office including staff supervision, verification of physician credentials and information, communications with physicians, hospitals and various agencies involved with medical staff services.

  2. Accountable for establishing, contributing, and implementation of standards applicable to medical staff members relating to credentialing, quality improvement, and administrative functions for responsible hospital and system.

  3. Complies with all regulatory standards, providing consultative expertise to the Medical Staff and hospital leadership on options and permissible actions in order to meet those standards.

  4. Communication: Provides a collegial environment which fosters teamwork both within the medical staff office, with other members of the medical staff service department and medical staff members of hospital. Professionalism in all aspects and commitment to the delivery of quality service.

  5. Financial/Budgeting: Assist in the development of the system medical staff service budget and manages resources within the budget once approved. Monitor operating budget and staffing level for consistency with departmental goals while maintaining a high level of customer service satisfaction.

  6. Provides on-going performance feedback, addresses problems, orients and trains employees, verifies competency and identifies and suggests way to develop skills. Monitors workflow.

  7. Develops and implements departmental policies and procedures to comply with medical staff bylaws, medical staff policies/procedures, TJC/CMS requirements and related state and federal regulations.

  8. Ensure all provider credentials meet the requirements as outlined by Hospital Medical Staff Bylaws, TJC and state and federal regulatory agencies.

  9. Policies and Procedures: Maintain, create and revise policy and procedures related to database management collaboratively within the department and what best meet the system medical staff functions, hospital bylaws, managed are policies, TJC requirements, and related state and federal regulations.

  10. Professional Development: Maintains professional growth by participating in educational programs and professional organizations. Maintain knowledge of current industry standards, regulations, trends, practices, and developments.

  11. Reporting/Data Management: Manages data entry of physician information into practitioner files, status reports and productivity reports for correctness and accuracy. Evaluates software needs of credentialing database management to fulfill needs of medical staff office operations. Maintain a file audit program ensuring audit and survey preparedness.

  12. Coordinates transmittal of complete and timely credentials file through the various review committees and board approval.

  13. Periodic evaluation of data gathering process required to ensure organizational needs are consistently met.

  14. Maintains current, accurate demographic and credentials data on Medical Staff.

  15. Monitors monthly that all licenses and certifications remain current at 100% level.

  16. Facilitate monthly Medical Staff Committee meetings: including agenda planning, coordinating meals, taking minutes, follow-up on action items, and other duties as assigned.

  17. Monitor Joint Commission/CMS medical staff standards to ensure compliance.

  18. Input and manages Peer Review software to meet requirements as per Joint Commission standards on FPPE and OPPE.

Required Education:

Minimum Qualifications:  Bachelor’s degree in health care or management related field preferred. Five (5) years comprehensive Medical Staff Services in an acute care hospital, and/or credentialing verification with three (3) years of supervisory experience. This position requires strong communication, critical thinking, a self-starter, mathematical and analytical skills, and the ability to formulate computerized reports.


Required Certifications/Licensure: CPMSM Certification (Certified Professional Medical Staff Management) or must become certified within one year of hire into role and maintain with required CEs thereafter.


Required Training: Clinical experience or demonstration of deep understanding of medical terminology and processes; Demonstrated successful experience at leadership and team building; Effective professional business written and verbal communication skills; Demonstrated excellent organization and time management skills and ability to manage multiple priorities effectively; Technical knowledge of automated support system and office software. Must have a good working knowledge of Excel Level II, Word Level II, and be proficient in PowerPoint. 


Work Experience:  Five (5) to seven (7) years related work experience. 

Position Available: 10/19/2020
Date Posted: 09/10/2020
Contact Information: Effingham Health System
Kimberly Chadbourne
Email resume and salary requirements to:


Georgia Association Medical Staff Services

Questions? Contact Us at:

PO Box 4413  |  Valdosta, GA 31604


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