Director, Medical Staff Office

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Beth Israel Deaconess Medical Center
May 12, 2021
Boston, Massachusetts
Job Type


State City Organization

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Director, Medical Staff Office

Department Description: Beth Israel Deaconess Hospital-Needham (BID Needham) is a licensed 58–bed acute care hospital offering the same care as our direct affiliate Beth Israel Deaconess Medical Center (BIDMC) in your community.
This close affiliation with BIDMC, since 2000, has facilitated the clinical integration of staff and resources in emergency medicine, hospital medicine (hospitalists), cardiology, radiology, orthopaedics, general surgery, pathology and oncology. Physicians in Needham maintain very close relationships with the staff at BIDMC; so in cases where patients need to be transferred from Needham to Boston for more advanced care, there are systems in place to make that transition happen quickly.Job Location: Needham, MA

Req ID: 39411BR

Job Summary: Oversee physician and allied health practitioner credentialing, recredentialing and privileging in accordance with State, Joint Commission and other applicable standards. Work in collaboration with the CMO and medical staff leadership to carry out the hospital's mission to deliver quality patient care and provide a supportive environment for the medical staff. Ensure communication between medical staff and Board committees regarding quality, patient care, policies and process improvement. Maintain ACCME accreditation standards for physician and nursing CME programs.

Essential Responsibilities:

    1. Oversee the credentialing and privileging process for physicians and allied health practitioners in accordance with the Medical Staff Bylaws, Joint Commission, State and managed care standards. Ensure credentialing staff are educated on regulatory changes affecting credentialing. Develop and maintain departmental and Medical Staff policies and procedures.
    2. Communicate credentialing and medical staff issues to Department Chairpersons, Service Chiefs, Credentials Committee and legal counsel as appropriate and coordinate processes for resolution.
    3. Assist the Credentials Committee with the development of privilege criteria, quality data collection and other documents necessary for an effective credentialing process.
    4. Maintain residency practice guidelines and required documentation for BIDMC residents and residents from area fellowship programs.
    5. Work in collaboration with the CEO and medical staff leadership to provide data, perform research and maintain a working knowledge of the Medical Staff Bylaws and Rules and Regulations for appropriate advisement.
    6. Act as a liaison between the Corporate Compliance Officer and physicians to report potential issues. Collaborate with the Corporate Compliance Officer to develop compliance materials for physicians.
    7. Ensure communication between medical staff committees to the Medical Staff Executive Committee, Quality Care Committee and Patient Care Assessment Committees regarding quality and patient care issues, policies and process improvement.
    8. Communicate effectively with physicians, affiliated practices, business associates, and BILH to ensure integration of newly credentialed physicians.
    9. Maintain ACCME accreditation for the hospital's CME program for physicians and nurses. Oversee coordination of weekly Grand Rounds and joint education activities between the full medical staff and BILH. Report to the Medical Education and Library Committee.
    10. Coordinate and attend physician practice site visits with other department managers to educate off-site staff about new and existing hospital services. Work with the Marketing Department to ensure current services are reflected in electronic and written materials.
    11. Has the authority to direct and support managers with functional area responsibilities. Has the direct responsibility to undertake the following employment actions: hiring, termination, corrective action and performance reviews. Direct Reports: 4-6 Indirect Reports: 1-5
    1. Has full responsibility for planning, monitoring and managing department budget.

Required Qualifications:

  1. Bachelor's degree in Business or Health Related required.
  2. 1-3 years related work experience required in Medical Staff Office position and 1-3 years supervisory/management experience required
  3. Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint or Access and other web-based applications. May produce complex documents, perform analysis and maintain databases.


  1. Decision Making: Ability to make decisions with significant, broad implications for the management and operations of a major department or multiple departments. Participates in decisions on overall strategy and direction of the organization.
  2. Problem Solving: Ability to address problems that are highly varied, complex and often non-recurring, requiring staff input, innovative, creative, and Lean diagnostic techniques to resolve issues.
  3. Independence of Action: Ability to set direction and vision for major departments or multiple departments. Establishes priorities, develops policies and allocates resources.
  4. Written Communications: Ability to communicate complex information in English effectively in writing to all levels of staff, management and external customers across functional areas.
  5. Oral Communications: Ability to verbally communicate complex concepts in English and address sensitive situations, resolve conflicts, negotiate, motivate and persuade others.
  6. Knowledge: Ability to demonstrate broad and comprehensive knowledge of theories, concepts, practices and policies with the ability to use them in complex and/or unprecedented situations across multiple functional areas.
  7. Team Work: Ability to lead collaborative teams for larger projects or groups both internal and external to the Medical Center and across functional areas. Results have implications for the management and operations of multiple areas of the organization.
  8. Customer Service: Ability to lead operational initiatives to meet or exceed customer service standards and expectations in assigned unit(s) and/or across multiple areas in a timely and respectful manner.

Physical Nature of the Job:
Sedentary work: Exerting up to 10 pounds of force occasionally in carrying, lifting, pushing, pulling objects. Sitting most of the time, with walking and standing required only occasionally


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