Hackensack Meridian Health

Mgr, Medical Staff Services - Full Time - Day

Job ID
Riverview Medical Center
Job Location
US-NJ-Red Bank
Position Type
Full Time with Benefits
Standard Hours Per Week
Shift Hours
Weekend Work
No Weekends Required
On Call Work
No On-Call Required
Holiday Work
No Holidays Required


Our team members are the heart of what makes us better. At Hackensack Meridian Health we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It’s also about how we support one another and how we show up for our community. Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.

The Medical Staff Services Manager provides direction and leadership in all areas of Medical Staff services support and the credentialing process. Assists Medical Staff Leadership in development, implementation and adherence to Medical Staff organization governing structure and documents, as well as adherence to accrediting body and state/federal regulatory requirements.


1. Manages appropriate and timely assessment of appointments and reappointment to the Medical Staff, delineation of clinical privileges and associated credentialing functions. Works closely with Medical Staff. Assures accuracy of appointment and reappointment documentation.

2. Assists Medical Staff Leadership in development, implementation and adherence to Medical Staff organization governing structure and documents, as well as adherence to accrediting body and state/federal regulatory requirements.

3. Maintains integrity of systemwide computer-based physician information system, communicates with tech support, MHS Information Systems Dept. and Medical Staff users as necessary. Effectively manages projects and personnel in systems development.

4. Develops and implements annual goals in accordance with the goals of the organization and in accordance with regulatory and licensing entities as they relate to the credentialing and privileging process.

5. Develops and implements departmental policies and procedures related to the daily operations of the department as monitored by the supervisor.

6. Supervises staff to ensure that they are performing job duties accurately and in accordance with the timelines established by departmental policy and medical staff bylaws/policy as monitored by supervisor.

7. Organizes and maintains medical staff credentials files as evidenced by survey results, documentation, supervisor observation.

8. Holds staff meetings to review and resolve problems, provide information, identify opportunities for improvement and develop any necessary action plan for problem resolution as monitored by supervisor and documentation.

9. Develops capital and operating budget for Credentials Department; meets budgetary guidelines as monitored by monthly financial reports.

10. Maintains on-going relationship with credentialing software representatives, implements software updates and makes recommendations regarding updates needed to ensure efficiency and compliance with privileging processes.

11. Develops and uses query function of credentialing software to produce reports as requested by internal and external customers.

12. Ensures credentialing and privileging processes and documents meet regulatory standards and the needs of the organization.

13. Revises delineation of privilege forms to conform with the revised Joint Commission standards of criteria-based core competency privileging compliance with privileging process as monitored by supervisor.

14. Revises and maintains forms used in the appointment, reappointment and provisional period in accordance with regulatory requirements as monitored through document review. 15. Demonstrates working knowledge of standards and regulations and makes recommendations needed to the medical staff policies, bylaws and/or the privileges process in order to ensure compliance as monitored.

16. Establishes a process for ensuring that physician profiles and any other information relating to competency and behavior are submitted to the Department Chairs at the time of reappointment as evidenced by feedback from the Chairs.

17. Attends Credentials Committee meetings and prepares agenda and credentials files needed for committee review. 18. Prepares minutes of the Credentials Committee in a timely manner. Submits a Credentials Committee report to the Medical Council monthly.

18. Attends Medical Executive Committee meetings and prepares agenda and files needed for committee review. Prepares minutes of the Medical Executive Committee in a timely manner.

19. Coordinates the semi- Annual Medical Staff meeting, as requested by the AVP Medical Administration.

20. Oversees the Medical Staff finances. Ensures the medical staff invoices are sent in accordance with the medical staff bylaws with follow-up as outlined in the bylaws.

21. Monitor medical staff Medical Directorships with processes outlined by CMO and Corporate Compliance.

22. Other duties and/or projects as assigned

23. Adheres to HMH Organizational competencies and standards of behavior.


Education, Knowledge, Skills and Abilities Required:

1. Bachelor's degree or over 10 years prior credentialing experience.

2. Minimum of 3 years managerial experience or equivalent experience.


Education, Knowledge, Skills and Abilities Preferred:

1. Minimum of 5 years professional experience directing the credentialing process for a similar sized organization (approximately 50 candidates per month).

2. Experience managing and mentoring junior staff NAMSS (National Association Medical Staff Services) Certification.

3. Demonstrated skills in balancing the needs of the organization with the need to properly serve and onboard physicians.

4. Understanding of different models of physician affiliation and employment.


Licenses and Certifications Preferred:

1. NAMSS Certification.


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