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Manager of Medical Staff Services
Manager of Medical Staff Services-March 2024
Cypress
Mar 31, 2026
About Manager of Medical Staff Services

  At Houston Methodist, the Manager Medical Staff Services position is responsible for the management and administration of the Medical Staff Services department, functions and staff. Functional areas of responsibility of this position may include many of the following: credentialing; Medical Staff governance, including peer review; accreditation and regulatory compliance; departmental operations; supporting the key Committees of the Medical Staff including, but not limited to, Executive Committee, Bylaws & Rules Committee, Credentials Committee, Practitioner Health Committee, and Procedures and Criteria Committee; and general activities of the organized Medical Staff. This position manages and on occasion, performs the credentialing and privileging of medical staff for services to be performed at the Hospital and provides for the coordination of all medical staff meetings, including agenda and minutes of the meeting. Other duties for the Manager Medical Staff Services position include providing oversight to maintaining currency of the Medical Staff Bylaws, and coaching medical staff related to the requirements of the Bylaws. This position establishes and maintains constructive lines of communication between physicians and the hospital, fostering positive on-going relationships. The Manager Medical Staff Services position also leads efforts to monitor, assess and recommend changes to policies and procedures for the effectiveness of operational practices supporting physician Bylaws and improving medical staff relationships with the Hospital. This position provides back-up coverage and support for the Director, as needed.

  The manager position responsibilities include managing the daily work activities of the work unit/department staff, ensuring quality, productivity, functional excellence and efficiency while assisting management in accomplishing strategic and operational objectives. In addition, this position provides guidance to staff and is responsible for staffing, budget compliance, contributing to staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and assisting in the development and implementation of policies and procedures to ensure a safe and effective work environment. This position also implements training, monitoring and operations initiatives that secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations.

  PEOPLE ESSENTIAL FUNCTIONS

  Performs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees in the department. Provides development and mentoring of staff. Meets or exceeds threshold goal for department turnover. Develops direct reports to perform these same functions.

  Provides fair and consistent leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem.

  Facilitates and promotes effective team dynamics and teambuilding strategies within and between departments; participates and/or leads and facilitates department process improvements as needed.

  Meets or exceeds threshold goal for department and/or system metrics on employee engagement indicators.

  Develops, in conjunction with other system hospital leaders, a comprehensive orientation for new physicians and allied health professionals.

  SERVICE ESSENTIAL FUNCTIONS

  Plans and organizes day-to-day department operations, schedule and activities. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction.

  Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department.

  Manages the coordination and provision of medical staff activities to include medical staff meetings, recording of meetings consistent with requirements of Medical Staff Bylaws, Rules and Regulations, and government/accreditation/regulatory requirements.

  Provides oversight to, manages, and on occasion, performs the credentialing and privileging of medical staff for initial and reappointment for approved services to be performed at the Hospital, ensuring compliance with all regulatory applications to such.

  Oversees creation, distribution, and updating of accurate monthly on-call physician schedules for Emergency Department coverage.

  Collaborates with the Director, other Executives, Hospital Leadership Team and Board of Trustees in developing, maintaining, and enhancing physician relations, services and communication between the medical staff and the hospital to promote quality health care delivery and physician loyalty and satisfaction.

  Manages the coordination of physician compensation, including payments for Committee Service, Leadership and ED Call.

  Frames and manages projects and initiatives end-to-end; maintains responsibility for deliverables, timelines, and stakeholder buy-in. Data mines information and produces reports in a meaningful way for decision making in support of continued departmental development.

  QUALITY/SAFETY ESSENTIAL FUNCTIONS

  Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines.

  Uses and optimizes information systems to enhance operations; supports entity-specific performance improvement and data management/analysis functions.

  Employs a proactive approach in the optimization of safe outcomes by monitoring and improving the department workflow, using peer-to-peer accountability, and identifying solutions via collaboration. Adopts lean principles in driving process improvements. Role models situational awareness, using teachable moments to improve safety.

  Monitors self and employee compliance with policies, procedures, and System HR Standards of Practice and performs associated actions upon non-compliance (i.e., focal point review requirements, disaster plan, inservices, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.).

  Coordinates resolution of physician issues, working with Director, risk management, patient safety, system legal, and medical staff leadership as appropriate related to Peer Review, competency and physician behavior.

  Regularly communicates with Medical Executive Committee members, Medical Staff Department and Committee chairs, Medical Staff Officers to assist in solutions to problems or issues. Provides guidance and oversight to ensure compliance with Medical Staff Bylaws and Rules and Regulations, government/accreditation regulations and standards affecting the medical staff organization, hospital organizational policies and procedures, and credentialing and privileging procedures.

  FINANCE ESSENTIAL FUNCTIONS

  Assists in the development of department budget and ensures that the department operates in a cost effective manner. Manages/audits department expenses within approved budget parameters, ensuring that the department meets the budgeted/flex revenue and/or expense targets on a monthly and annual basis. Develops staffing plans and schedules to meet department needs that reflect understanding of the importance of cost-effectiveness.

  Implements department strategies to achieve financial target and staffing needs, developing others to do the same, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications.

  GROWTH/INNOVATION ESSENTIAL FUNCTIONS

  Identifies and implements innovative solutions for practice or workflow changes to improve department operations or other department-specific measures by leading unit projects and/or other department/system directed activities. Supports change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures.

  Proactively evaluates processes; recommends and implements action plan(s) for change; follows through to ensure effective, sustainable change. Participates in the development and implementation of new procedures and the review and revision of existing procedures.

  Identifies opportunities and takes action to build strategic relationships between one's area and other areas, teams, departments, and units to achieve business goals.

  Seeks opportunities to identify developmental needs of self and staff and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development plan on an on-going basis. Conducts conversations with staff on their development.

  This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

  EDUCATION

  Bachelor's degree in a relevant field

  Master's degree preferred

  WORK EXPERIENCE

  Three years of experience in medical staff services in a hospital or medical services in other related healthcare environment

  Three years of people management experience; For Houston Methodist employees, three years of progressively responsible experience within applicable field

  LICENSES AND CERTIFICATIONS - REQUIRED

  N/ALICENSES AND CERTIFICATIONS - PREFERRED

  CPCS - Certified Provider Credentialing Specialist (NAMSS) OR

  CPMSM - Certified Professional Medical Services Management (NAMSS) OR

  CPHQ - Certified Professional in Healthcare Quality (NAHQ)

  KNOWLEDGE, SKILLS, AND ABILITIES

  Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

  Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

  Ability to effectively communicate through a variety of channels with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles; engages the recipient(s) and helps them understand and retain the message

  Demonstrates the ability to interact with others in a way that gives them confidence in one's intentions and those of the organization

  Ability to use appropriate interpersonal styles and techniques to gain acceptance of ideas or plans; modifying one's own behavior to accommodate tasks, situations and individuals involved

  Demonstrates leadership qualities and critical thinking through self-direction initiative and effective interpersonal skills and oral/written communication skills

  Ability to identify and understand issues, problems and opportunities, comparing data from different sources to draw conclusions; using effective approaches for choosing a course of action or developing appropriate solutions; taking action that is consistent with available facts, constraints and probable consequences

  Ability to work effectively in a fast paced environment

  Demonstrates flexibility and adaptability in the workplace

  General knowledge of performance improvement methodologies; strong ability to evaluate and develop effective process improvements to enhance efficiency of operations

  Advanced skill in use of spreadsheet and relational database software

  Skill in developing and maintaining interpersonal relationships as required in the work environment

  Solid understanding of hospital medical staff operations

  Demonstrated ability to manage multiple projects and priorities as well as comfort and confidence operating within a matrix organization

  Solid knowledge of State and Federal law relating to medical staff operations, the Health Insurance Portability and Accountability Act of 1996, regulatory/accreditation agency standards and elements of performance, Medical Staff Bylaws and Rules and Regulations, and Continuing Medical Education

  Must demonstrate a high level of leadership skills to effectively interface between the hospital, medical staff, administration and Board

  Strong presentation skills preferred

  SUPPLEMENTAL REQUIREMENTS

  WORK ATTIRE

  Uniform No

  Scrubs No

  Business professional Yes

  Other (department approved) No

  ON-CALL*

  *Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

  On Call* YesTRAVEL**

  Travel specifications may vary by department

  May require travel within the Houston Metropolitan area Yes

  May require travel outside Houston Metropolitan area Yes

  Company Profile:

  Houston Methodist Cypress Hospital is scheduled to open in 2025 as the ninth hospital in the Houston Methodist system. Cypress, which will be master planned for 500 beds, will be modeled after Houston Methodist West and Houston Methodist The Woodlands hospitals. It will be designed as the hospital of the future and will be a testament to Houston Methodist’s commitment to innovation.

  The hospital, located at Highway 290 between Barker-Cypress and Jarvis Road, will include medical office buildings to house our breast care center, cancer and infusion center, orthopedics and sports medicine and multi-specialty physician practices.

  Houston Methodist is an equal opportunity employer inclusive of women, minorities, disabled persons and veterans.

  Equal Employment Opportunity

  Houston Methodist is an Equal Opportunity Employer.

  Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law. VEVRAA Federal Contractor – priority referral Protected Veterans requested.

  Houston Methodist is an Equal Opportunity Employer.

  Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law. VEVRAA Federal Contractor – priority referral Protected Veterans requested.

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