Job Description

The Quality and Medical Staff Director will have shared oversight of the facility-wide Performance Improvement Program with the Chief Quality Officer. The leadership role will direct others within the facility towards process improvements that will support the reduction of medical/health care errors and other factors that contribute to unintended adverse patient outcomes. This role will work with the CQO to provide leadership for safety assessments, educates other practitioners on the system-based causes for medical error, consults with management and staff, and communicates literature-based ideas regarding effective patient safety strategies to others within the organization.

The Quality and Medial Staff Director will also be responsible for coordinating the daily operation of the Quality Staff Office function under the guidance of the CQO. Supervisory responsibility for Credentialing, Ongoing Clinical Practice, and will oversee Credentialing team members, Clinical Resource Analyst, and OPPE/FPPE team member.

Develop, direct, implement, maintain, and evaluate the credentialing program with emphasis on supporting the medical staff leadership, department chairpersons, and section chiefs to appoint qualified applicants for medical staff membership or reappoint current members to the medical staff. Monitor and maintain compliance with all regulatory, State, Federal government, and Joint Commission standards.

Ensure hospital-wide compliance with The Joint Commission standards. Provides oversight to ongoing monitoring and assessment of key quality indicators that are reported to the State, CMS, and The Joint Commission. Joint Commission readiness. This position reports directly to the CQO.


Preferred: BSN with current NM/Multi State RN licensure Required: Associates Degree with current NM/Multi State RN licensure 


Four years of experience in a health care setting with knowledge of Medical Staff functions, Credentialing, Supervisor or Manager in an acute care facility. Effective customer service and organizational skills, ability to use various computer applications – word processing essential, database experience preferred. Ability to communicate and effectively present information to internal and external groups and audiences. Attention to detail a must.


CPHQ, CPPS, CMSC or CPCS strongly preferred

Application Instructions

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