Houston Methodist Logo

Manager of Medical Staff Services

Job Ref: 27662

Talent Area: Administrative Management

Houston Methodist San Jacinto Hospital
Baytown, TX 77521

Area/Department: Med Staff Serv

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Houston Methodist San Jacinto Hospital, located 35 miles southeast of Houston, is the area's only full-service hospital offering specialized medical care for patients at every stage in life. This 392 licensed bed hospital with 18 operating rooms, and over 1,400 employees, brings Medical Center excellence and quality care close to East Harris and surrounding counties.

Job Summary

Responsible for the management and administration of the Medical Staff Services department, functions and staff. Manages activities and functions associated with physician practice and governance for the Hospital. Directs and on occasion, performs the credentialing and privileging of medical staff for services to be performed at the Hospital and provides for the coordination of all medical staff meetings, including agenda and minutes of the meeting. Provides oversight to maintaining currency of the Medical Staff By-laws, and coaching medical staff related to the requirements of the By-Laws. Establishes and maintains constructive lines of communication between physicians and the hospital, fostering positive on-going relationships. Leads efforts to monitor, assess and recommend changes to policies and procedures for the effectiveness of operational practices supporting physician bylaws and improving medical staff relationships with the Hospital. 


I. Provide personalized care and service by consistently demonstrating our I CARE values:

INTEGRITY: We are honest and ethical in all we say and do.

COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.

ACCOUNTABILITY: We hold ourselves accountable for all our actions. RESPECT: We treat every individual as a person of worth, dignity, and value.

 EXCELLENCE: We strive to be the best at what we do and a model for others to emulate. II. Focuses on patient/customer safety III. Delivers personalized service using HM Service Standards IV. Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words) V. Intentionally rounds with patients/customers to ensure their needs are being met VI. Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job


PEOPLE (5%) 1. Projects a positive customer service image and responds effectively when dealing with patients, family members, staff, physician, and other departments by integrating I CARE (Integrity, Compassion, Accountability, Respect, and Excellence) values into operational milieu.

SERVICE (5%) 1. Exhibits expected behaviors for patient and visitor interactions as outlined in the Service Pride program. Demonstrates ability to work effectively with physicians, hospital and departmental staff.

QUALITY/SAFETY (80%) 1. Manages the coordination and provision of medical staff activities to include medical staff meetings, recording of meetings consistent with requirements of Medical Staff Bylaws, Rules and Regulations, CMS, DNV-GL and other applicable regulatory requirements. 2. Provides oversight to, manages, and on occasion, performs the credentialing and privileging of medical staff for initial and reappointment for approved services to be performed at the Hospital, ensuring compliance with all regulatory applications to such. 3. Oversees creation, distribution, updating accurate monthly on-call physician schedules for Emergency Department coverage. 4. Provides for orientation, networking, Continuing Medical Education opportunities for ongoing development of physicians. 5. Coordinates resolution of physician issues, working with Director, Hospital Risk Manager and/or Patient Safety Officer, System legal, and medical staff leadership as appropriate related to Peer Review, competency and physician behavior. 6. Partners with Human Resources to ensure compliance of dependent allied health personnel (non-employees) brought in under the sponsorship of a physician(s) to ensure compliance with DNV-GL standards, CMS standards, and hospital policies and procedures. 7. Collaborates with the Director, other Executives, Hospital Leadership Team and Board of Trustees in developing, maintaining, and enhancing physician relations, services and communication between the medical staff and the hospital to promote quality health care delivery and physician loyalty and satisfaction. 8. Regularly communicates with Medical Executive Committee members, Medical Staff chairs, Chief of Medical Staff to assist in solutions to problems or issues. Provides guidance and oversight to ensure compliance with Medical Staff Bylaws and Rules and Regulations, Joint Commission Standards, CMS, State and Federal regulations affecting the medical staff Page 3 of 5 organization, hospital organizational policies and procedures, and credentialing and privileging procedures. 9. Manages department human resources in accordance with policies and procedures for achieving desired outcomes to include selection, counseling, development, coaching of employees; develops and manages the department budget and is accountable for financial performance.

FINANCE (3%) 1. Works with Director to prepare and manage departmental budget; ensuring financial responsibility of the Medical Staff Services department. 2. Self-motivated to independently manage time effectively and prioritize tasks for self and other support staff.

GROWTH/INNOVATION (7%) 1. Responsible for coordination and implementation of new standards as required by regulatory and accrediting agencies; including implementation of new or improved policies and procedures related to the Medical Staff Services department. 2. Data mines information and produces reports in a meaningful way for decision making in support of continued departmental development. 3. Seeks opportunities to expand learning beyond baseline competencies with a focus on continual development as a Medical Staff Services Manager. This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.


Bachelor’s degree in healthcare, finance or business administration or related field. Substantial experience may be accepted in lieu of required degree.


A minimum of five years experience in a healthcare-related field and three years in a Medical Staff Services leadership role to include medical staff credentialing and privileging, recording of medical staff meetings, oversight and maintenance of medical staff by-laws.


CPCS (Certified Provider Credentialing Specialist) and / or CPMSM (Certified Professional Medical Services Management) considered a plus and is preferred.


Hands-on, high-energy, people-oriented leadership style that has strong analytical, communication, and interpersonal skills.

Strong ability to evaluate and develop effective process improvements to enhance efficiency of operations.

Solid understanding of hospital medical staff operations.

Excellent decision-making judgment as well as strong analytical and problem-solving skills. Demonstrated ability to manage multiple projects and priorities as well as comfort and confidence operating within a matrix organization.

Proactive team-player with proven ability to manage and motivate a diverse team. 



Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.