Credentialing Officer-Medical Administrative Staff

Medical Staff Administrative / Credentialing Officer

The Medical Staff Administrative / Credentialing Officer is responsible for managing the hospital's medical staff services and credentialing program. This role ensures compliance with regulatory, accreditation, and hospital bylaws requirements while supporting medical staff leadership in governance, credentialing, privileging, and peer review. The officer serves as the liaison between hospital administration, medical staff leadership, and clinical departments to maintain an effective credentialing and privileging process.

Essential Functions

• Serve as the primary resource and liaison for the organized Medical Staff and its committees (e.g., Medical Executive Committee, Credentials Committee, Peer Review).
• Prepare agendas, minutes, and follow-up actions for medical staff committees and meetings.
• Ensure adherence to hospital Medical Staff Bylaws, Rules & Regulations, and Policies.
• Support the medical staff in governance, elections, and communications.
• Maintain accurate medical staff rosters, call schedules, and directories.
• Coordinate all aspects of credentialing, privileging, and recredentialing for medical staff and allied health professionals in accordance with hospital bylaws, CIHQ / Joint Commission, CMS, and state regulatory requirements.
• Verify credentials including licensure, education, training, board certification, work history, references, malpractice history, NPDB, OIG / SAM, and other primary source verifications.
• Track expirables (licenses, DEA, certifications, insurance, etc.) and maintain compliance.
• Manage and maintain credentialing database (e.g., MD-Staff, Echo, or internal system).
• Work collaboratively with department chairs and clinical leadership to facilitate privilege delineation and competency review.
• Ensure compliance with CIHQ / Joint Commission, CMS Conditions of Participation, and state regulatory standards related to medical staff services and credentialing.
• Support peer review, quality monitoring, and FPPE / OPPE processes.
• Prepare credentialing and privileging files for survey readiness and audits.
• Provide reports to administration, quality council, and governing body as needed.

Requirements

Skills & Competencies

Physical & Working Conditions