Medical Staff Credentialing Administrator
About the role
Develop, build, and maintain clinician delineation of privileges (DOP) forms within the credentialing and privileging software system.
Translate approved Medical Staff Rules & Regulations, bylaws, policies, and specialty criteria into structured, standardized electronic privilege forms.
Ensure privilege language reflects current clinical practice, regulatory requirements, and accreditation standards (e.g., Joint Commission, CMS).
Perform regular review and updates of privilege forms to reflect changes in scope of practice, technology, clinical standards, or organizational initiatives.
Monitor and track special, advanced, and condition-based privileges across specialties.
Ensure required qualifications, proctoring, focused professional practice evaluation (FPPE), and ongoing professional practice evaluation (OPPE) elements are built into the privileging framework.
In collaboration with the department of Quality, carry out the FPPE & OPPE review and approval with Medical Staff leaders, including Chiefs, Chairs, Service Line Leaders, Medical Executive Committees, and Chief Medical Officers.
Prepare draft proposals, revisions, comparison documents, and summary materials to support informed physician leadership decision-making.
Collaborate with Medical Staff leadership to define, refine, and document specialty-specific privileging parameters and performance metrics and requirements.
Support consistent application and compliance with privileging criteria across departments and locations.
Monitor privileging practices for compliance with regulatory, accreditation, and internal policy requirements.
Conduct routine audits and data reviews related to privilege assignments, expirations, and special privilege tracking including robotic surgery, sedation, fluoroscopy, and laser use, ensuring adherence to medical staff governance requirements, regulatory expectations, and patient safety standards.
Prepare reports, dashboards, and analyses to support leadership oversight, quality initiatives, and accreditation readiness.
Identify trends, gaps, or risks and recommend solutions.
Serve as a content expert for privileging data within the credentialing system.
Maintain documentation of privileging processes, standards, and governance decisions.
Serve as a backup to the Lead Credentialing Specialist.
Participate in department projects, policy development, education, and process improvement initiatives.
Qualifications
- Associate’s degree in healthcare administration, business, or a related field required
- Bachelor’s degree preferred
- Equivalent combination of education and experience considered
- Minimum of 3–5 years of experience in Medical Staff Services, credentialing, or privileging required
- Demonstrated experience with delineation of privileges, special privileging, or physician governance processes strongly preferred
- Experience working directly with physician leaders and executive medical staff committees preferred