Processes initial applications and reappointments for acute care hospital facilities.  Ensure that all credentialed practitioners are processed in accordance with hospital policy/medical staff bylaws and that all elements of the credentialing and privileging process, as well as other departmental functions, are carried out efficiently and thoroughly. Monitors renewals of licensure/certifications/insurance and updates credentialing software.  Independently conducts medical staff-related business and projects as necessary. Obtains documentation supporting each application to the Medical Staff.   including the coordination and distribution of all information required to maintain effective communication among the members of the Medical Staff.  Ensures compliance with all laws and regulatory relations regarding medical staff files and membership.


  • High School diploma or equivalent.
  • Some college courses are helpful.
  • A minimum of two years experience working with a hospital medical staff.
  • Good clerical skills, including word processing.
  • Understand the medical staff credentials process.
  • Good organizational and communication skills.


  • Meets all required deadlines. Demonstrates discretionary ability in establishing priority.
  • Process all initial medical staff and allied health professional applications promptly per medical staff bylaws, rules, and regulations. Coordinate processing new applicants for medical staff privileges and gathering supporting data.  Assists in any follow-up necessary for deferred applications.  Prepare appointment letters to be sent after approval by the Board of Managers.
  • Maintains complete documentation of Medical Staff files. Responds to routine correspondence on own.  Attend and record minutes of the annual meeting of the entire medical staff as requested.
  • Maintains medical staff and AHP’s files safely and confidentially.
  • Audits and monitors MSO software for licensures and insurance for medical staff and AHPs. Assists in maintaining medical staff and AHP’s in Meditech System and INet.
  • Handles medical staff and other hospital information of a confidential nature with great care and tact. Maintains all physician files safely and confidentially.  Minimize opportunities for legal discovery of confidential peer review information.
  • Demonstrates professionalism in communications with patients and staff. Promotes professionalism in dealing with other members of the healthcare delivery team.  Develops an understanding of other departments and works to coordinate mutual functions.
  • Maintains full compliance with JCAHO and licensing standards. Monitors requirements of JCAHO and state and federal agencies and makes necessary adjustments to maintain compliance.  Communicate with the Department Director about compliance status and make recommendations about the department’s needs to stay current.
  • Utilizes Meditech EMR
  • Performs other duties as assigned.

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