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Manager, Medical Staff

Job ID R-51279 Date Posted 09/19/2023 Location Burlingame, California Schedule/Shift/Weekly Hours Regular/Days/40


MPHS-Mills-Peninsula Medical Center

Position Overview:

Provides overall leadership, direction and management of the activities and resources of the Medical Staff Services department. Provides support to the Medical Staff organization to meet the goals and objectives of the medical staff and hospital and to meet requirements of licensure and regulatory agencies. Establishes protocols and practices, ensuring compliance with department, affiliate, operating unit, and/or system standards, policies and procedures and applicable laws and regulations. Takes a strategic and tactical approach in identifying best practices and standardizing workflows/processes and developing plans of action to implement changes.

Job Description:

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).


• Manages the daily and strategic activities of the Medical Staff Services department maximizing the use of available resources to ensure efficiency, high standards, compliance and productivity.
• Responsible for supporting and assisting medical staff leadership in carrying out their responsibilities as outlined in the governance documents and policies and procedures.
• Builds and maintains effective working relationships and communicates effectively with the medical staff, their office personnel, hospital departments and administration.
• Identifies and works to remove barriers that may hinder the achievement of process/productivity improvement and efficiency.
• Provides guidance and direct intervention in resolving challenging or complex situations.
• Develops, implements and/or ensures corrective action plans are implemented to address or minimize operational risk.
• Keeps leadership informed of operations and escalates complex issues requiring higher level intervention.

• Develops and/or updates and maintains applicable governance documents (e.g., medical staff bylaws, credentialing policies and procedures, rules and regulations) that support and direct organizational practices and that comply with regulatory requirements, accreditation standards, and organizational policies and procedures.
• Remains current on accreditation requirements, state/federal regulations, medical staff bylaws, rules and regulations, and policies and procedures governing the organization.
• Leads departmental goal setting process and provides roadmap for accomplishing goals. Monitors progress, developing action plans to address issues and challenges.
• Communicates affiliate, operating unit and system goals to staff, helping staff understand impact on operations and resources.
• Develops plan of action to address current and future resource needs in order to meet service and/or operational demands and objectives.

Financial Management
• Monitors operational budget that supports medical staff services and credentialing functions by evaluating financial and resource information.
• Monitors department productivity, ensuring operational challenges are addressed timely.
• Reviews financial reports and develops and implements corrective action plans to address unfavorable variances.
• Reviews and approves employee expense reimbursements, and billing statements from vendors according to established protocol.

• Provides and fosters an inclusive work environment that encourages staff engagement and collaboration, establishing a culture of teamwork.
• Supervises assigned staff, makes hiring and termination decisions, and reviews and approves timekeeping records.
• Establishes expectations with all direct reports, holds individuals and work teams accountable, and ensures job descriptions accurately reflect job responsibilities and expectations.
• Evaluates staff performance and makes/recommends associated merit increase. Provides constructive feedback, coaching and counseling. Implements disciplinary actions and/or performance improvement plans to achieve desired performance. May work with leadership when major disciplinary action is necessary or in consultation with Human Resources.
• Provides opportunities for career development, role expansion, and cross-training.
• Monitors department training and orientation plans, ensuring staff meets competency requirements and participates in appropriate education and training programs.
• Ensures staff maintains current and appropriate professional credentials.

Equivalent experience will be accepted in lieu of the required degree or diploma.

Bachelor's: Business Administration, Healthcare or related field or equivalent education/experience


8 years recent relevant experience


Proven working relationship with Medical Staff or physician groups.

Knowledge of Medical Staff functions and processes, bylaws and rules and regulations.

Demonstrated knowledge of PC, especially word processing, database and spreadsheet software (proficient in MS Office (Word, Excel, Power Point). Familiar with external and internal database program and practical applications in the department.

Ability to interrelate with and gain respect of physicians, nurses and other hospital personnel.

Interpersonal skills with the ability to collaborate with diverse groups of people.

Able to ensure a high level of accuracy and productivity in supervising and performing all areas of work output by establishing and maintaining quality standards and a high expectation of accountability.

Demonstrates tactical and analytical thinking and planning skills, and is able to develop plan to accomplish objectives, identify obstacles and resolve operational issues.


See required physical demands, mental components, visual activities & working conditions at the following link: Job Requirements

Job Shift:



Full Time

Shift Hours:


Days of the Week:

Monday - Friday

Weekend Requirements:






Position Status:


Weekly Hours:


Employee Status:


Number of Openings:


Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $44.94 to $67.41 / hour

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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