Senior Director-Medical Staff Services-Office of the Hospital President

Job Description

Strength Through Diversity

Ground breaking science. Advancing medicine. Healing made personal. 


Office of the Hospital President-Req # 2453580

Senior Director-Medical Staff Services


The Senior Director, Medical Staff Services is the administrative liaison between the Medical Staff and Hospital Administration and the Board of Directors. Leadership accountability is expected in managing practitioner competency systems; policies, procedures and legal governance documents; support of Medical Staff Leadership; Medical Staff Services (MSS) operations; Medical Staff and hospital collaboration and leadership by demonstrating current practices and by using and integrating technology. The Director is responsible for developing systems that support the Medical/Professional Staff and Hospital’s mission and strategic plan. A key performance area is regulatory and accreditation knowledge and compliance. 

The Senior Director, Medical Staff Services supervises the activities of the Director, Manager, Coordinator, Specialists and/or Assistant as applicable.

Role & Responsibilities:

A. Plans, organizes and directs a comprehensive credentialing program 
• Directs all aspects of the credentialing functions for appointments and reappointments.
B. Designs, implements and manages an objective, criteria-based clinical privileging system
• Ensures that clinical privileges performed are criteria-based and reflective of current services offered by the organization and encompasses licensed independent practitioners (LIPs) and advanced practice practitioners (APPs).
• Works in conjunction with the hospital quality department on aspects related to the privileging functions relative to peer review and professional performance profiles.
• Remains up- to- date on new procedures, techniques and equipment relative to Medical Staff Services and general knowledge of procedures, techniques and equipment that may impact Medical Staff privileging.
• Controls the monitoring of procedure-established criteria to ensure that practitioners meet qualifications for eligibility to request and retain specific privileges.
• Works with other hospital personnel to ensure that practitioners practice within the scope of their privileges.
C. Interprets, develops and implements practices of all systems and functions to ensure continuous compliance with applicable regulatory agencies and accrediting bodies as applicable e.g., CMS, DNV JC, NCQA, AOA-HFAP, AAAHCDNV, etc.
• Provides ongoing education to team and Medical Staff Leaders as necessary.
• Participates on hospital compliance teams and in regulatory and accreditation surveys, as needed.
D. Collaborates with other hospital personnel regarding performance improvement data to help Medical Staff Leaders make informed decisions regarding practitioner competence
• Collaborates with key staff on managing an ongoing reporting process that is accurate, timely and action driven.

A. Controls and directs the administrative support of governance documents 
• Ensures that all governance documents, policies, procedures, rules and regulations are compliant and current.
• Protects permanent records by managing a secure record retention process.

A. Plans and manages an effective Medical Staff meeting management system 
• Directs meeting activities (agenda development, documentation, follow-up, communication).
• Provides guidance on accreditation, regulatory issues, medico-legal implications, national standards of care, best practices, meeting outcomes and resolution.
B. Plans and manages the administrative support to Medical Staff Leadership allowing them to effectively carry out their duties and responsibilities
• Collaborates, develops and implements long and short-term goals.
• Manages processes related to investigative, disciplinary and legal proceedings, such as fair hearing and appeal. 

A. Directs and manages the strategic and daily activities of the department
• Responsible for adequate staffing and efficient use of staffing resources
• Establishes standards and analyzes work procedures that promote leading practices and champions innovation.
• Controls and manages budget.

A. Directs the administrative interface with Medical Staff Leaders and Medical Staff organization and hospital administration, the Governing Body and hospital departments to assure and enhance effective relationships 
• Serves as a liaison between Medical Staff and Administrative Leadership.

A. Supports education, professionalism, practice-based learning and systems-based learning
• Responsible for recruiting, training, mentoring, evaluating and disciplining departmental staff.
• Cultivates positive interpersonal relationships with the members of the Medical Staff, Medical Staff Leaders and Administrative and ancillary staff.
• Promotes ongoing education.


Bachelor’s degree preferred; Graduate degree in Business or Healthcare Administration.

Minimum of 10 years’ experience in an acute healthcare facility in a leadership position working with Medical Staff leaders, e.g. Medical Staff Services, Quality/Performance Improvement, Physician Recruitment, etc.


Strength Through Diversity

The Mount Sinai Health System believes that diversity is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize medicine together.


We work hard to acquire and retain the best people, and to create a welcoming, nurturing work environment where you can develop professionally. We share the belief that all employees, regardless of job title or expertise, can make an impact on quality patient care. 


Explore more about this opportunity and how you can help us write a new chapter in our story! 


Who We Are

Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.

Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospital campuses, including Mount Sinai Beth Israel, Mount Sinai Beth Israel Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.


The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation. 


EOE Minorities/Women/Disabled/Veterans


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