Executive Director, Medical Staff Affairs

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Req #: 10368
Division: Quality
Employment Type: Full Time
Shift: Day
Compensation Type: Salaried
Facility: John Peter Smith Hospital
Location: 1500 S. Main Street, Fort Worth, TX


Description: The Executive Director, Medical Staff Affairs is responsible for leadership, oversight and coordination of the Medical Staff Office for JPS Health Network. Typical Duties:

  1. Provides oversight of the credentialing and privileging functions for the appointment and re-appointment processes for physicians, advanced practice providers (APP), and allied health professionals.
  2. Directly responsible for fiscal planning, budget and audits, and employee management. Prepares and monitors annual budget to ensure appropriate performance against objectives; anticipates opportunities for new services and programs and reduction of expenses in the organization. Assures compliance with regulatory requirements and quality management.
  3. Develops, organizes, and manages all operational functions of the Medical Staff Office.
  4. Directs and supports selection of an expert staff in assigned areas; conducts ongoing assessments and assumes responsibility for professional growth and development of staff to include workforce planning for areas of responsibilities.
  5. Develops goals, proactive strategies and functional objectives regarding credentialing, privileging, and assessment of provider competency to ensure compliance with regulatory guidelines and requirements; implements, plans and monitors progress of set goals, and revises plans as necessary, relative to areas of responsibility.
  6. Assures compliance with regulatory requirements and quality management, including supervision of continuous quality improvement efforts related to medical staff services.
  7. Provides oversight to the Physician Excellence Committee and all related peer review activities.
  8. Provides oversight of credentialing database.
  9. Responsible for Medical Staff Joint Commission chapter; ensures all elements of performance are met successfully.
  10. Oversees the review process of data collection and studies involving medical care evaluation/improvement efforts to include criteria for Ongoing Professional Practice Evaluation (OPPE) and triggers indicating need for Focused Professional Practice Evaluation (FPPE); facilitates interdisciplinary collaboration to ensure OPPE quality metrics are meaningful and appropriate for all specialties involving the Medical Staff; ensures completion by all medical staff every six months; tracks patient contacts by Physicians.
  11. Provides oversight of meeting management to medical staff committees ensuring timely distribution of necessary information and providing support staff.
  12. Ensures that appropriate national, regional and local rules and regulations as well as accreditation stands of The Joint Commission (TJC) are maintained; provides oversight of TJC survey preparation for the Medical Staff and Leadership.
  13. Works closely with Administration ensuring Medical Staff follows all Medical Staff Bylaws; ensures bylaws are in compliance with TJC and other regulatory requirements.
  14. Performs other duties as assigned.
  15. Adhere to internal controls and reporting structure.
  16. Performs other job related duties as assigned.



    Required Education and Experience:

  • Bachelor’s Degree in a healthcare or related field from an accredited university.
  • 5 plus years’ experience in a healthcare supervisory position.
  • 3 plus years’ experience in Quality Management or Medical Staff office.
  • Required Licensure/Certification/Specialized Training:

  • CPMSM (Certified Professional Medical Services Management) and CPCS (Certified Provider Credentialing Specialist)
  • Knowledge of healthcare-related regulatory and accreditation requirements and survey methods.
  • Preferred Education and Experience:

  • Master’s Degree in Healthcare or related field from an accredited university
  • Preferred Licensure/Certification/Specialized Training:

  • Current licensure by the Board of Nurse Examiners for the State of Texas or proof of reciprocity of licensure between the State of Texas and another state.


JPS Health Network is a $950 million, tax-supported health care system for Tarrant County in North Texas. Licensed for 578 beds, the network includes an acute care hospital and more than 40 community-based clinics, including 19 school-based clinics. John Peter Smith Hospital is home to Tarrant County’s first and only Level 1 Trauma Center, its only psychiatric emergency services site and has the largest hospital-based family medicine residency program in the nation. Our network employs more than 6,500 people.

Acclaim is our multispecialty medical practice group. Acclaim has over 300 providers serving the JPS Health Network in specialties ranging from primary care to general surgery and trauma. The Acclaim group has been formed around a common set of incentives and expectations supporting the operational, financial and clinical performance
outcomes of the network. Our goal is to provide high quality, compassionate clinical care for every patient, every time.

For more information, visit www.jpshealthnet.org .
To view all job vacancies, visit www.jobs.jpshealthnet.org/ or www.teamacclaim.org .