Job Title:
Medical Staff Services Supervisor
Report to:
HR Manager
Functional Reporting: CMO/CQO
Objective(s):
The Medical Staff Services Supervisor is responsible for supporting the day-to-day operations of the Medical Staff Office, including coordinating credentialing and privileging activities, maintaining accurate medical staff records, supporting medical staff committees, ensuring compliance with applicable policies and regulatory requirements, and facilitating effective communication among medical staff, administration, and relevant departments.
Core Job Responsibilities:
Pre-Operational Phase (2026–2027):
- Medical Staff Office Setup: support the establishment of the Medical Staff Office by coordinating the preparation of operational workflows, filing systems, templates, and tracking tools in alignment with governance structures and bylaws defined by senior leadership.
- Policies and Procedures Readiness: review draft medical staff policies and procedures and provide operational input to ensure they are practical, complete, and ready for implementation at opening.
- Initial Credentialing Pipeline: coordinate the initial credentialing and privileging process for medical staff, ensuring all applications, primary source verifications, and supporting documentation are complete ahead of hospital opening.
- Medical Staff Database Build: continue populating the medical staff database with complete, verified records of credentials, licenses, certifications, privileges, appointment status, and expiry dates for all medical staff.
- Committee Infrastructure Preparation: coordinate the scheduling, documentation frameworks, and communication protocols for medical staff committees prior to opening, ensuring all committee structures are operational and properly documented from day one.
- Regulatory Compliance Preparation: review applicable regulatory, accreditation, and licensing requirements and ensure all pre-opening credentialing activities and documentation meet required standards. Coordinate with relevant departments to address compliance gaps prior to opening.
- Staff Onboarding Support: assist in onboarding Medical Staff, including orientation to systems, workflows, and assigned responsibilities, ensuring the team is fully operational at launch.
- Stakeholder Coordination: liaise with medical leadership, legal, and IT to ensure that all interdependencies related to medical staff setup are resolved prior to the operational launch date.
Post-Opening Phase (2027+):
- Medical Staff Office Operations: support the day-to-day functions of the Medical Staff Office in accordance with established governance structures, bylaws, and policies. Maintain medical staff membership records, classification updates, and adherence to the code of conduct and professionalism policies.
- Policies and Procedures Compliance: ensure compliance with medical staff office policies and procedures, including credentialing and privileges, performance evaluation processes, CPD requirements, and quality improvement protocols.
- Medical Staff Credentialing and Privileges: coordinate and oversee the credentialing and privileging process for medical staff, including physicians, physician assistants, and dentists, ensuring timely and accurate completion of applications and verification of credentials.
- Regulatory Compliance: support compliance with applicable regulatory, accreditation, and licensing requirements related to medical staff services.
- Meeting coordination: coordinate and schedule medical staff meetings, maintaining accurate records of minutes and action items.
- Medical Staff Committees: facilitate communication between medical staff committees, administration, and relevant departments.
- Assist with periodic peer reviews of medical staff members, in coordination with the quality department, to ensure that they are maintaining their competence.
- Assist in resolving complaints about medical staff members.
- Provide education and training to medical staff members on credentialing and privileging requirements.
- Medical Staff Database Management: oversee the medical staff database, ensuring accurate and up-to-date information on credentials, licenses, and certifications.
- Quality Improvement: support continuous quality improvement initiatives related to medical staff services. Identify operational inefficiencies in the credentialing process and recommend improvements to the relevant manager for consideration and approval.
Qualifications requirements:
- Bachelor’s degree in healthcare or a related field.
- Five to seven years of experience in healthcare administration.
- Experience coordinating administrative workflows or projects within a healthcare setting.
- Excellent organizational, communication, and interpersonal skills.
