Director, Medical Staff Services, Corona Regional Medical Center, Corona, CA

Posted on September 22nd, 2025

SERVICE EXCELLENCE STANDARDS

Establish A Service-Minded Culture:

• Demonstrates effective relationship building with patients/customers.

Demonstrate Professionalism And Excellence In The Things I Do:

• Takes ownership/accountability for role in Service Excellence.
• Accepts role as a leader and serves as a positive role model.
• Focuses on solutions for problems, not causes.

Practice Teamwork:

• Participates in decision making and process improvement.
• Effectively communicates verbally and non-verbally.
• Demonstrates awareness and understanding of HCAHPS and own role in driving HCAHPS scores.

Service Recovery:

• Listens to patient/customer concerns/complaints and addresses issues using service recovery techniques, including empathy and blameless apology. If unable to resolve, moves the issue to the most appropriate person."

POSITION SUMMARY
Under the direction of the Chief Executive Officer and the Chief Medical Officer, the Director of Medical Staff Services oversees all internal and external activities of the Medical Staff and is responsible for all operational aspects of the department, including organizing and conducting programs and establishing procedures for medical staff functions. Responsible for maintaining Federal, State and other licensing regulatory standards. Coordinates meeting agendas, minutes and follow-up. Acts as liaison between administration and hospital medical staff. Supervises Medical Staff personnel.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

BUDGET RESPONSIBILITY:

• Planning – Assist with budget preparation for assigned department(s).
• Meeting Objectives – At a minimum, the department operates within stated budget guidelines as measured by the specific unit of service, with the goal of exceeding budget projections.
• Cost Control – Effectively controls department costs and prepares for fluctuations and unexpected costs. Identifies cost reduction opportunities on a regular basis and recommends implementation when necessary.
• Productivity – Monitors and assists leadership with adjusting FTE levels to achieve budgeted staffing based on volumes, organizational goals, accepted staffing models within the industry, and patientcare needs defined by law, physician orders and/or a standardized workload measurement system.
• Capital Equipment/Procurement – Participates in the selection of vendors for needed services not otherwise prescribed; anticipates and budgets capital equipment following the policy while seeking to identify alternatives to capital purchasing.

ORGANIZATIONAL RESPONSIBILITY:

• Service Excellence – Treats everyone with dignity and respect and encourages collaborative relationships with colleagues, community providers, patients and family members. Documents all customer service responses and consistently identifies ways to improve customer service and feedback while reducing customer/patient complaints.
• Participation – Regularly attends Leadership, m3 and staff recognition events.
• Policy Development – Develops and implements laws and procedures that guide and support the provision of services.

HUMAN RESOURCES:

• Recruitment/Staffing – Maintains adequate staffing levels and responds to shortages/turnover as required with a minimum impact on services; recommends a sufficient number of qualified and competent persons for providing care and treatment.
• Retention – Takes appropriate action and interventions to retain quality staff. Notifies HR of employee resignation providing adequate notice for exit interview and processing. Maintains department turnover at or below facility annual goal.
• Performance Management – Determines the qualifications and competence of department personnel who provide services and who are not licensed as independent practitioners. Provides continuous feedback to employees and processes 90-day and annual evaluations by the due date100% of the time. Develops, counsels, disciplines and terminates staff as necessary, following all hospital human resources policies. Reviews and evaluates the work and productivity of staff.
• Staff Requirements – Assures timely compliance with staff job requirements to which may include, annual FIT Testing, TB, Flu Vaccination, LMS, licensure and certifications.
• Staff Development – Identifies the learning needs of all staff and contributes to meeting those needs. Teaches others in areas of expertise. Identifies own education needs and seeks appropriate learning experience.
• Conflict Resolution – Provides mechanisms for open feedback and communication from staff. Identifies situations of potential conflict and provides timely intervention always following policy and procedures utilizing appropriate resources.

LEADERSHIP:

• Flexibility/Adaptability – Displays positive traits and qualities needed for a successful manager; has the ability to work with changes in the environment and participate as a team player.
• Initiative – Takes the responsibility for creating innovative programs and continuously strives to improve department services and organizational performance. Establishes and implements department goals and objectives in order to improve service delivery.
• Medical Staff – Maintains a positive relationship with the Medical Staff and identifies opportunities to improve service relations.
• Employee Recognition – Utilizes Service Excellence program to recognize and reinforce exceptional customer service and staff performance.
• Rounding – Actively rounds on patients and staff. Acts as a resource for interdisciplinary care rounds.
• Department Communication – Conducts regular staff meetings and provides written minutes for staff. Communicates facility wide information/updates as appropriate.
• Interdepartmental Communication – Collaborates with peers and demonstrates innovative use of system wide resources to facilitate consistent practices, policies, and appropriate utilization of staff.
• Town Hall Meetings – Encourage department staff participation at Town Hall meetings with a goal to exceed 50%.
• Employee Engagement Survey – Staff participation in bi-annual survey meets or exceeds 80%.Action plan results are used to identify areas of opportunity and an action plan is developed and implemented.
• Committees/Work Groups – Encourages and facilitates staff level participation in committees and work groups.
• Facility Moral Building Activities – Encourages and facilitates staff level participation in facility sponsored events.

QUALITY:

• Process Improvement - Leader is actively engaged in PI process, using data to drive improvements.
• Quality Targets - Department and facility quality targets are met.
• Regulatory - Leader is actively engaged in maintaining survey readiness. Areas of opportunities are corrected timely.
• Develops and maintains department Quality Improvement Program.

GENERAL DUTIES:

• Participates in Emergency Preparedness Drills. Demonstrates through practice drills and upon request understanding of his/her role in the event of an emergency or disaster.
• Facilitates departmental and hospital educational activities and services in conjunction with the Education Department.
• Responsible for development, review and revision of departmental written policies and procedures.
• Ensures that the department has equipment, supplies necessary to provide consistent quality and service delivery.
• Reports any unsafe situations or safety hazards immediately. Labels and removes any malfunctioning equipment from service and notifies Engineering.

POSITION SPECIFIC RESPONSIBILITIES:

• Maintains a positive and professional relationship with the Medical Staff and Allied Health Professionals to include identification of opportunities to improve service relations.
• Establish, implement, and ensure that Medical Staff practices and procedures are in accordance with The Joint Commission, Title 22, and other Federal, State, and regulatory agencies, as well as overall Hospital policies.
• Coordinate and maintain all Medical Staff Governance documents to include but not limited to Medical Staff Bylaws, General Rules and Regulations, and Departmental/Division Rules and Regulations, Policies and Procedures.
• Coordinate all aspects of Medical Staff Committee and Departmental meetings including but not limited to staffing, scheduling, preparing materials and notices prior to meetings to include agenda and meeting packet, document proceedings, maintain records, meeting minutes and perform all follow up actions post meeting.
• Provide resources and education to all Medical Staff, Medical Staff Leaders, department/service line leaders and staff, as well as other health care professionals in the development of mechanisms to assess physician performance, identify potential risks, and initiate decisive and timely actions as necessary and when appropriate.
• Serves as the liaison between the Medical Staff, Administration, Board of Governors, ancillary departments, and patients in matters pertaining to Medical Staff.
• Works collegially with and provides necessary supporting documentation to the Regional Credentialing Verification Organization (CVO).
• Responsible for continuous maintenance of accurate and confidential files and database programs specific to Medical Staff and Allied Health Professionals.
• Provides daily supervision, education and guidance to Medical Staff personnel.
• Actively participates on performance improvement committees and activities to maintain and improve quality of patient care and safety, collaborates with other service line leaders in developing/improving workflow practices that impact the patient experience and overall services to all internal and external customers.

JOB QUALIFICATIONS

EDUCATION/TRAINING/ EXPERIENCE:

• Bachelor's degree from an accredited College or University in related field required.
• Master's degree from an accredited College or University in related field preferred.
• Five (5) to Seven (7) years of experience in Medical Staff Services required.
• Minimum 3 years leadership experience in Medical Staff Services required, acute care experience preferred.
• Regulatory and Accreditation knowledge, critical thinking, attention to details, organization and time management skills are essential.

CERTIFICATIONS/LICENSES:

• Certified Professional in Medical Services Management (CPMSM) required.
• Certified Provider Credentialing Specialist (CPCS) preferred.

COMMUNICATION SKILLS: Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, regulatory or accreditation requirements. Ability to write reports, business correspondence, policies and procedures. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.

MATHEMATICAL SKILLS: Basic to Intermediate Skills: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Ability to calculate figures and percentages. Ability to work with statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

REASONING ABILITY: Intermediate to High Skills: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

OTHER SKILLS AND ABILITIES:

• Demonstrates knowledge and ensures compliance with The Joint Commission and Title 22 standards and guidelines.
• Demonstrates compliance with hospital policies and procedures at all times.
• Demonstrates strong leadership, organization, communication and interpersonal skills.
• Demonstrates ability to relate to clinical personnel and medical staff, as well as ability to interact well with the public.
• Must have knowledge of PC and applications.
• Capable of resolving escalated issues arising from operations and requiring coordination with other departments.
• Regulatory and Accreditation knowledge, critical thinking, attention to details and time management skills are essential.
• Physician relationship and conflict management skills.
• Strong written and oral communication skills.