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Position Summary:

The System Manager of Medical Staff Services is responsible for leading and coordinating all aspects of medical staff operations across the health system, including credentialing, privileging, medical staff governance, and professional practice evaluations. This role ensures that processes meet the standards of regulatory and accrediting bodies, and align with medical staff bylaws, policies, and institutional goals. Reporting directly to the Chief Medical Officer (CMO), the System Manager supports physician quality, safety, and performance through comprehensive management of the credentialing life cycle and a robust, fair, and timely peer review program.

Qualifications:

Required:

+ Bachelor’s Degree in healthcare administration, public health, or related field.

+ Current Certified Professional of Medical Services Management (CPMSM) credential from the National Association of Medical Staff Services (NAMSS), or the ability to obtain within twelve (12) months of hire.

+ Three (3) years of progressive responsibility in medical staff services, peer review processes, credentialing, and credential verifications.

+ Two (2) years in a supervisory or managerial capacity, including experience managing peer review processes.

+ Intermediate understanding of medical staff governance, credentialing databases, and healthcare regulations.

+ Intermediate understanding of Ongoing Professional Practice Evaluation (OPPE), Focused Professional Practice Evaluation (FPPE), and peer review protections.

Preferred:

+ Master’s degree in healthcare administration, public health, or related field.

+ Certified Provider Credentialing Specialist (CPCS).

Essential Job Functions: In addition to the essential functions of the job listed below, employees must have on-time completion of all required education as assigned per DNV requirements, Bozeman Health policy, and other registry requirements.

+ Oversee all processes related to initial appointment, reappointment, clinical privileging, and peer review of medical staff and advanced practice clinicians (APCs) while ensuring credentialing information is accurate, verifiable and secure.

+ Coordinate and manage the peer review process, including case reviews, committee scheduling, documentation, follow-up, and maintenance of confidentiality, ensuring compliance with bylaws and regulatory standards.

+ Serve as the administrative lead and content expert for peer review committees; collaborate with medical staff leaders and quality department to support clinical performance evaluations and quality assurance activities.

+ Support medical staff governance, including Medical Executive Committee (MEC) and Credentials Committee activities, agenda preparation, and documentation.

+ Ensure full compliance with accreditation standards (e.g., DNV, TJC) and state/federal regulations governing credentialing, privileging, and peer review.

+ Collaborate with the CMO, legal/risk, and compliance to ensure defensible processes for fair hearing plans, focused professional practice evaluation (FPPE), and ongoing professional practice evaluation (OPPE).

+ Maintain practitioner data integrity, including licensure, certifications, insurance, and disciplinary history by utilizing a Credentials Verification Organization (CVO).

+ Coordinate with Human Resources, Quality, Risk Management, and Clinical Leadership on cross-functional provider performance issues.

+ Lead continuous improvement initiatives within medical staff services to enhance quality, timeliness, and efficiency of credentialing, OPPE, FPPE, and peer review workflows.

+ Serve as the system liaison for regulatory audits, accreditation surveys, and legal reviews related to credentialing and peer review.

Knowledge, Skills and Abilities

+ Comprehensive knowledge of credentialing, privileging, and professional practice evaluations, bylaws, and regulatory/accreditation requirements (TJC, DNV, CMS, NPDB).

+ Proven ability to lead peer review coordination in a confidential, unbiased, and legally sound manner.

+ Strong facilitation, presentation, and communication skills, especially when working with physicians and clinical leaders.

+ Skilled in interpreting and applying medical staff bylaws, rules, and policies in complex or sensitive scenarios.

+ Adept in workflow optimization and credentialing software with a Credentials Verification Organization (CVO).

+ Highly organized and detail-oriented with the ability to manage multiple priorities and meet deadlines.

+ Maintains discretion and sound judgment in handling confidential provider information.

Schedule Requirements

+ This role requires regular and sustained attendance.

+ The position may necessitate working beyond a standard 40-hour workweek, including weekends and after-hours shifts.

+ On-call work may be required to respond promptly to organizational, patient, or employee needs.

Physical Requirements

+ Lifting (Rarely – 30 pounds): Exerting force and/or using a negligible amount of force to lift, carry, push, pull, or otherwise move objects or people.

+ Sit (Continuously): Maintaining a sitting posture for extended periods may include adjusting body position to prevent discomfort or strain.

+ Stand (Occasionally): Maintaining a standing posture for extended periods may include adjusting body position to prevent discomfort or strain.

+ Walk (Occasionally): Walking and moving around within the work area requires good balance and coordination.

+ Climb (Rarely): Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like using feet and legs; may also use hands and arms.

+ Twist/Bend/Stoop/Kneel (Occasionally): Twisting, bending, stooping, and kneeling require flexibility and a wide range of motion in the spine and joints.

+ Reach Above Shoulder Level (Occasionally): Lifting, carrying, pushing, or pulling objects as necessary above the shoulder, requiring strength and stability.

+ Push/Pull (Occasionally): Using the upper extremities to press or exert force against something with steady force to thrust forward, downward, or outward.

+ Fine-Finger Movements (Continuously): Picking, pinching, typing, or otherwise working primarily with fingers rather than using the whole hand as in handling.

+ Vision (Continuously): Close visual acuity to prepare and analyze data and figures and to read computer screens, printed materials, and handwritten materials.

+ Cognitive Skills (Continuously): Learn new tasks, remember processes, maintain focus, complete tasks independently, and make timely decisions in the context of a workflow.

+ Exposures (Rarely): Bloodborne pathogens, such as blood, bodily fluids, or tissues. Radiation in settings where medical imaging procedures are performed. Various chemicals and medications are used in healthcare settings. Job tasks may involve handling cleaning products, disinfectants, and other substances. Infectious diseases due to contact with patients in areas that may have contagious illnesses.

*Frequency Key: Continuously (100% - 67% of the time), Repeatedly (66% - 33% of the time), Occasionally (32% - 4% of the time), Rarely (3% - 1% of the time), Never (0%).

The above statements are intended to describe the general nature and level of work being performed by people assigned to the job classification. They are not to be construed as a contract of any type nor an exhaustive list of all job duties performed by the personnel so classified.

77211200 Human Resources