Medical Staff Office Director & Designated Institutional Official for GME

Job Summary

The Medical Staff Office Director & Designated Institutional Official (DIO) for Graduate Medical Education (GME) is responsible for overseeing the medical staff credentialing and privileging processes, while also leading the institution’s GME programs in compliance with ACGME (Accreditation Council for Graduate Medical Education) standards. This dual role ensures that both patient care quality and medical education excellence are maintained through effective administration, regulatory compliance, and strategic leadership.

The Designated Institutional Official (DIO) should demonstrate a deep understanding of graduate medical education (GME) and possess a proven ability to build trust and collaborate effectively with physicians across specialties. While not an MD, the ideal candidate brings comfort and confidence in engaging with clinical faculty and residents, fostering a supportive and compliant learning environment.

Key Responsibilities:

Medical Staff Office Director Responsibilities:

• Oversee and manage the credentialing, privileging, and reappointment processes for all medical staff, advanced practice providers, and allied health professionals.
• Maintain compliance with accrediting bodies, CMS, state regulations, and internal policies.
• Serve as liaison between hospital administration and the medical staff, ensuring strong communication and alignment.
• Facilitate medical staff committee meetings, including Credentials Committee, Medical Executive Committee (MEC), and others.
• Manage medical staff bylaws, rules, and regulations and ensure timely updates.
• Coordinate peer review processes, FPPE/OPPE processes, and support quality initiatives.
• Supervise and train Medical Staff Office personnel.
• Maintain accurate and up-to-date credentialing database systems.
• Coordinate the Provider on call schedule.
• Provide administrative support to physician leadership, i.e. budgets and schedules as designated by the CEO.

Designated Institutional Official (DIO) for GME Responsibilities:

• Serve as the ACGME-required DIO and have authority and accountability for all GME programs sponsored by the institution.
• Ensure institutional compliance with ACGME Institutional Requirements.
• Lead strategic planning and development for new residency and fellowship programs.
• Collaborate with Program Directors and the Graduate Medical Education Committee (GMEC) to monitor program quality, resident performance, and institutional GME outcomes.
• Ensure residents and fellows have a safe, supportive educational environment, including duty hour compliance, supervision, and well-being.
• Serve as primary contact with ACGME and other accrediting bodies.
• Oversee and track GME budget with hospital leadership and participating sites.
• Promote faculty development, scholarly activity, and diversity within training programs.
• Approve program letters of agreement (PLAs) that govern relationships between each program and each participating site providing a required assignment for residents in the program I.A.5.b).(1).
• Oversee submissions of the Annual Update for each program and the Sponsoring Institution to the ACGME I.A.5.b.(2).
• After GMEC approval, oversee the submission of applications for ACGME accreditation and recognition, request for voluntary withdrawal of accreditation and recognition and request for changes in residency and fellowship program complements. ACGME I.A.5.b).(3).

Minimum Job Requirements

• Bachelor’s degree in Business, Public Health, Education or related field.
• Five (5) years’ experience in a medical staff services leadership role.
• Three years’ experience of progressive responsibility in GME or academic medicine.
• Demonstrated knowledge of ACGME requirements, medical staff credentialing processes, and healthcare regulations.

Preferred Job Requirements

• Master’s degree in Healthcare Administration, Public Health, Education, or related field.
• Certified Professional Medical Services Management (CPMSM).
• Certified Provider Credentialing Specialist (CPCS).
• AAMC GME Leadership certificate.

Skills / Knowledge / Abilities

• Strong leadership and team management skills.
• Excellent knowledge of regulatory requirements and healthcare accreditation standards.
• Exceptional organizational, communication, and problem-solving abilities.
• Ability to foster collaboration among departments and external partners.
• Proficient with credentialing, quality, incident reporting system software and Microsoft Office Suite.
• Proactive, results-oriented approach to management, sound problem-solving and decision-making ability, well-developed interpersonal skills to interact in sensitive and/or complex situations with a variety of people.
• Ability to promote teamwork and build effective relationships.
• Very high level of communication skills to effectively communicate verbally and in writing.
• Ability to foster cooperative and effective working relationships with the management team, Board of Directors, business/community associates and the community at large.
• Ability to attend meetings, seminars and/or conferences on behalf of the corporation.
• Knowledge of policies, governmental regulations and business practices pertinent to the department.
• Excellent time management, and organizational skills.
• Ability to problem solve, multi-task in a fast-paced setting and work well in a team environment.
• Ability to negotiate effective working relationships and develop positive resolution to conflict.
• Highly developed computer skills to include proficiency with Microsoft Office and the ability to learn and proficiently perform computer applications related to department operations and job function.
• Excellent customer service skills.
• Excellent management skills.
• Strong organizational, financial, leadership and administrative skills to manage multiple issues simultaneously combined with ability to effectively prioritize.
• Ability to effectively perform job functions under periods of extreme stress, meeting deadlines and producing positive outcomes.
• High degree of accuracy with concentration and close attention to detail.
• Commitment of 24-hour accountability.
• Ability to be discreet and protect the integrity of any confidential matter or information encountered during the performance of job duties.

Working Conditions

• Typical office environment with prolonged sitting and occasional standing and walking.
• Work may be subject to interruptions and occasional high stress levels.
• Ability to work extended hours or weekends based on the needs of the department.
• Works with highly confidential information which may be proprietary or protected health information.
• May attend special functions and meetings at various locations within Marion Health and community.
• Occasional overnight stays.

Physical and Mental Activities, Tools and Equipment

• Uses computer and standard office equipment.
• Repetitive wrist, finger and hand movements.
• Extreme concentration and attention to detail.
• Lifting standard office supplies or equipment.
• Lifting, pushing, pulling, walking, sitting, reaching, bending, kneeling or stooping to perform duties in a safe manner.

Equal Employment Opportunity
Marion Health is a smoke-free environment.