Medical Staff Services Director

Job Description

Job Description

orthern Light Radiology Associates is seeking an experienced Medical Staff Director to join our growing team. We are a successful hospital-based medical management company dedicated to operational excellence and collaborative teamwork. We’re looking for a driven professional who values partnership, leadership, and high-quality outcomes to support our continued growth.

The Medical Staff Services Director is responsible for overseeing all medical staff services functions for a large multi-state radiology practice, ensuring compliance with regulatory and accreditation requirements. This role leads credentialing, privileging, and ongoing compliance activities for radiologists. The Director serves as a key liaison between physicians, practice leadership, hospitals, and regulatory bodies, supporting high-quality, compliant, and efficient clinical operations.

Key Responsibilities

Medical Staff Services & Governance

• Direct all medical staff services operations for the radiology practice, including credentialing, privileging, reappointment, and peer review support.
• Develop, implement, and maintain medical staff policies, bylaws, rules, and procedures in alignment with best practices and regulatory standards.
• This position oversees the medical staff office staff of four credentialing coordinators

Credentialing & Privileging

• Oversee initial and ongoing credentialing and privileging for radiologists across hospitals, imaging centers, and practice locations.
• Ensure compliance with state specific licensure, supervision, scope of practice and telemedicine requirements.
• Ensure timely completion of reappointments, license renewals, board certifications, CME tracking, and sanction monitoring.
• This position is responsible for streamlining the credentialing and state licensing process.

Regulatory & Accreditation Compliance

• Ensure compliance with applicable regulations and standards, including CMS Conditions of Participation, Joint Commission, NCQA, URAC, and state medical board requirements.
• This position must have a complete and full understanding of the Joint Commission standards and guidelines.
• Monitor changes in regulatory requirements affecting radiology and medical staff services; update policies and processes accordingly.

Quality, Risk & Peer Review Support

• Ensure appropriate documentation, confidentiality, and due process for professional practice evaluations.
• This position interacts with hospital medical staff offices, Clinical Operations, Physician Scheduling, Revenue Cycle Management, Project Management, Market Expansion, Quality and Legal departments.

Leadership & Operations

• Lead, mentor, and develop medical staff services and credentialing team members.
• Establish performance metrics, workflows, and service-level expectations to ensure timely, accurate processing.
• Collaborate with operations, compliance, HR, legal, and IT teams to streamline provider onboarding and ongoing management.

Required Qualifications

• Bachelor’s degree in healthcare administration, business administration, or a related field; Master’s degree preferred.
• Minimum of 5-8 years of progressive experience in medical staff services, credentialing, or provider management, preferably in a large multi-site and specialty radiology practice.
• Demonstrated leadership experience managing teams and complex credentialing operations.
• In-depth knowledge of medical staff bylaws, credentialing standards and privileging requirements.

Preferred Certifications (not required)

• Certified Provider Credentialing Specialist (CPCS)
• Certified Medical Staff Services Professional (CPMSM)

Skills & Competencies

• Strong understanding of radiology practice operations and hospital-based medical staff relationships.
• Exceptional organizational skills with the ability to manage multiple deadlines and high provider volumes.
• Excellent written and verbal communication skills, including interaction with physicians and executives.
• High attention to detail with a strong commitment to confidentiality and compliance.
• Proficiency with credentialing and provider data systems (e.g., Cactus, MD-Staff, Echo, VerityStream) and Microsoft Office/Excel.
• Must be organized, able to proactively identify the needs of practice, well spoken, an excellent writer, logical, tactical and must at all times represent NL in a positive light.

Working Conditions

• On site
• Occasional extended hours during audits, surveys, or peak onboarding periods.

Reporting Relationship

• Reports to the Chief Administrative Officer or equivalent senior leader.

To learn more about Northern Light we encourage you to visit our website: www.northernlightmm.com.