About this role
Accountabilities:: Regulatory compliance and accreditation: Coordinate the planning, development, and implementation of regulatory standards and process improvements related to licensed independent practitioners, ensuring alignment with Joint Commission (JC), Centers for Medicare & Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and applicable state and federal requirements. Medical staff governance: Provide guidance and oversight to Medical Staff Offices to ensure that Medical Staff Bylaws, standard privileges, hospital regulations, procedural rules, and supporting documentation remain accurate and compliant with organizational policies and accreditation standards. Policy development and maintenance: Develop, review, and recommend updates to systemwide policies, procedures, Medical Staff Bylaws, and Hospital Regulations and Procedural Rules to support consistent organizational practices and ongoing regulatory compliance. Professional practice evaluation: Collaborate with healthcare quality leaders and medical group stakeholders to standardize quality indicators across specialties and oversee the implementation and monitoring of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) requirements. Database administration and optimization: Serve as the system administrator and subject matter expert for MD-Stat and related statistical applications, ensuring database integrity, security, functionality, accurate data collection, and effective reporting. Auditing and performance monitoring: Conduct regular database audits, monitor completion of quality metrics, identify compliance gaps, and coordinate corrective actions with Medical Staff Coordinators and Performance Improvement Directors. Training and stakeholder support: Develop educational materials and deliver guidance on database applications, professional practice evaluation processes, credentialing requirements, and governance procedures to relevant teams. Cross-functional project management: Lead and support special projects in collaboration with the Chief Medical Officer, Chief Quality Officer, Healthcare Quality and Safety leadership, Legal, Compliance, and Medical Group stakeholders. International medical staff oversight: Provide guidance to medical staff coordination teams in Canada and Mexico on credentialing, privileging, regulatory compliance, and data integrity. Governance and committee coordination: Lead collaborative initiatives and support steering committees focused on improving OPPE/FPPE processes, standardizing specialty-specific metrics, and evaluating performance thresholds. Operational improvement: Research complex issues, analyze performance data, identify improvement opportunities, and implement solutions that strengthen governance, efficiency, and quality outcomes. Enterprise collaboration: Maintain relevant professional services collaboration platforms and documentation repositories, ensuring effective information sharing and consistent communication across the organization. Requirements: Professional experience: At least 5 years of experience in a healthcare environment, particularly in medical staff services, healthcare quality, credentialing, or professional governance. Regulatory expertise: Strong working knowledge of CMS Conditions of Participation, Joint Commission accreditation standards, NCQA requirements, and applicable federal and state regulations governing healthcare credentialing and professional practice. Medical staff governance: Understanding of medical staff credentialing, privileging, bylaws, hospital regulations, and professional practice evaluation processes. Database management: Demonstrated experience with database administration, including data querying, reporting, document generation, data integrity monitoring, and database maintenance. Technical proficiency: Strong Microsoft Office skills, particularly the ability to work with reporting tools, databases, and documentation systems. Education: High school diploma or GED required. Preferred education: Associate's or bachelor's degree in a relevant healthcare discipline is preferred. Specialized software experience: Familiarity with statistical database platforms such as MD-Stat and Virtual Committee is an advantage. Professional certification: Certification through the National Association of Medical Staff Services (NAMSS), particularly as a Certified Professional in Medical Services Management (CPMSM), is preferred. Project management skills: Ability to coordinate complex, cross-functional initiatives, manage competing priorities, meet deadlines, and drive projects through implementation. Analytical capabilities: Strong research, problem-solving, auditing, and data analysis skills, with the ability to identify compliance risks and recommend effective solutions. Communication and collaboration: Excellent written and verbal communication skills, with the ability to build productive relationships with clinical leaders, administrative teams, and external stakeholders. Leadership and adaptability: Ability to influence without direct authority, facilitate teamwork, provide guidance to diverse stakeholders, and operate effectively in a complex, multi-site healthcare environment. Attention to detail: Strong organizational skills and commitment to accuracy, confidentiality, regulatory compliance, and continuous improvement. Benefits: Comprehensive healthcare coverage: Medical, dental, and vision insurance options. Retirement planning: Retirement savings program with employer matching contributions. Education and professional development: Tuition assistance to support continued learning and career advancement. Meaningful work: Opportunity to contribute to healthcare quality, patient safety, and improved outcomes for children and their families. Collaborative environment: Work alongside multidisciplinary healthcare professionals and experienced organizational leaders. Remote flexibility: Remote position based in the United States. Compensation: Salary determined according to relevant professional experience and internal departmental equity. Career development: Opportunities to participate in systemwide projects, quality initiatives, and professional governance programs. How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best! Why Apply Through Jobgether? Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time. #LI-CL1
- LOCATION
- Remote · US, United States
- WORK MODE
- Remote
- JOB TYPE
- Full-time
- POSTED
- Oct 30, 2026
Source: Jobgether Careers