When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
Reports to the Director and manages the day-to-day operations of the Medical Staff Services Office. Works collaboratively with the Manager of Provider Enrollment, Medical Staff Leadership, and Hospital Leadership to organize and maintain systems that coordinate the credentialing and re-credentialing process for all Lahey Hospital and Medical Center (LHMC) providers.Job Description:
Essential Duties & Responsibilities including but not limited to:
1. Provides direct leadership and oversight of the Medical Staff Services Department (MSSD) team, ensuring effective daily operations, consistent application of policies, staff development, performance monitoring, and a commitment to operational excellence.
2. Collaborates with the system Credentials Verification Office (CVO), Hospital Leadership, and Legal Counsel to support providers through the application process, ensuring timely appointment, reappointment, privileging, and management of credentialing expirables in compliance with Medical Staff Bylaws, Rules and Regulations, hospital policies, and applicable regulatory requirements, including those of The Joint Commission (TJC), the National Committee for Quality Assurance (NCQA), and state and federal agencies.
3. Oversees staff and ensures the timely and accurate credentialing, recredentialing, and privileging of providers affiliated with the hospital.
4. Manages and coordinates the timely submission of data and documentation for delegation audits by insurance plans, as applicable.
5. Ensures the accuracy, completeness, and integrity of provider data entered into the credentialing database by the MSSD staff.
6. Oversees and manages the maintenance and organization of electronic provider records in accordance with regulatory and organizational standards.
7. Partners with system and physician leadership to develop new clinical privilege forms or revise existing forms to reflect current practice and regulatory expectations.
8. Conducts regular team meetings to communicate updates, address concerns, and support team cohesion and performance.
9. Conducts regular staff meetings.
10. Responsible for recruiting, training, mentoring, and evaluating staff, as well as fostering their ongoing professional development.
11. Participates in the development and monitoring of the departmental budget, including variance reporting and resource planning.
12. Monitors departmental productivity and develops strategies to optimize operational effectiveness and efficiency.
13. Develops new policies and procedures, and oversees the routine review, revision, and enforcement of existing policies to ensure regulatory and organizational compliance.
14. Coordinates all aspects of assigned Medical Staff committee meetings—including the Credentials Committee, Medical Executive Committee, and Medical Staff Appointment Committee of the Board—ensuring accurate preparation of agendas, minutes, reports, and timely follow-up on actions.
15. Oversees the implementation, coordination, and management of the Focused Professional Practice Evaluation (FPPE) and Ongoing Professional Practice Evaluation (OPPE) processes.
16. Maintains current knowledge of and ensures compliance with all relevant regulatory and accreditation standards, including TJC/DNV, NCQA, CMS, and state and federal laws, as well as Medical Staff Bylaws and hospital policies.
17. Promotes a culture of excellence, professionalism, and customer service in all internal and external interactions and represents the organization positively in all external engagements.
18. Performs other related duties as assigned to support departmental and organizational goals.
Organizational Requirements:
1. Maintain strict adherence to the BILH Confidentiality policy.
2. Incorporate BILH Standards of Behavior and Guiding Principles into daily activities.
3. Comply with all Departmental Policies.
4. Comply with behavioral expectations of BILH.
5. Maintain courteous and effective interactions with colleagues, providers, and BILH leadership.
6. Demonstrate an understanding of the job description, performance expectations, and competency assessment.
7. Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to BILH customer service standards.
8. Participate in departmental and/or interdepartmental quality improvement activities.
9. Participate in and successfully completes Mandatory Education.
10. Perform all other duties as needed or directed to meet the needs of the department.
Key Relationships:
Minimum Qualifications:
Required Qualifications:
Preferred Qualifications:
Pay Range:
$80,000.00 USD - $130,000.00 USDThe pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.
Anna Jaques Hospital is a 123 bed community hospital serving 17 cities and towns in the Merrimack Valley . The hospital offers a wide range of acute care services to meet the needs of our growing patient population including inpatient and outpatient surgery in fully digitized computerized operating room suites, cardiology including echocardiography and a cardiac cath lab, comprehensive cancer services, orthopedics, nuclear medicine, laboratory, noninvasive vascular lab, joint replacement program and birth center.
Programs include the number one wound center in the nation, a primary stroke service, and Level III Trauma Center . Diagnostic imaging services for patients include MRI, CT, PET, and the PACS digital x-ray system. In addition, we are one of only three healthcare communities to be selected for the pilot Massachusetts e-Health Collaborative. Due to the dedication of our physicians, we are one of the first communities in Massachusetts to implement electronic health records, system-wide, for the safety of our patients.

The hospitals Non Invasive Vascular laboratory was accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL).
For the second year in a row, the American Association for Respiratory Care awarded the hospital its Quality Respiratory Care Recognition. The hospital had no ventilator acquired pneumonia cases during the last year.
The Wound Healing & Hyperbaric Center is the only such center to receive full accreditation from the Undersea and Hyperbaric Medical Society (UHMS) in Massachusetts .
The hospital is accredited by The Joint Commission, an organization that surveys and rates the performance of hospitals at least every three years. The Joint Commission Dedicated, good employees are one of your strengths. You have a lot to be proud of.