Position Summary

The Vice President, Medical Affairs (VPMA) serves as the senior physician leader responsible for medical staff governance, physician professional practice standards, and regulatory oversight across Luminis Health. Reporting to the Executive Vice President & Chief Physician Executive (CPE), the VPMA provides leadership for credentialing, peer review, physician accountability, medical staff policy development, and accreditation readiness.

The VPMA partners closely with medical staff leadership, physician leaders, hospital administration, and legal/compliance teams to ensure fair, evidence-based, and consistent physician governance structures across the system. This role champions professional accountability, physician self-governance, clinical integrity, and compliance with regulatory and accreditation standards.

Operating within a highly collaborative environment, the VPMA strengthens medical staff alignment and consistency across employed and independent physicians while supporting uniform medical staff governance and care standards across Luminis Health.

The VPMA serves as a trusted physician leader who promotes professionalism, fairness, transparency, and physician engagement while preserving the integrity of medical staff governance processes.

Essential Functions & Responsibilities

1. Medical Staff Governance & Professional Standards

• Provide executive leadership for medical staff governance structures across the system.
• Oversee credentialing, privileging, peer review, physician conduct, and professional practice evaluation processes.
• Ensure consistency and integrity of medical staff bylaws, rules, regulations, and policies.
• Support medical staff leadership in advancing physician accountability and professional standards.
• Promote a culture of patient safety, quality improvement, evidence-based practice, and a uniform clinical approach across the medical staff.
• Promote and support efforts to advance IT into clinical care workflows in a standard fashion.
• Represent the organization and medical affairs function in key internal and external forums.

2. Regulatory & Accreditation Oversight

• Lead physician-related regulatory readiness and accreditation activities.
• Partner with Quality, Compliance, and Legal leadership to ensure adherence to CMS, Joint Commission, state, and specialty accreditation standards.
• Support organizational readiness for audits, surveys, and regulatory reviews.
• Monitor evolving regulatory requirements impacting physician practice and governance.

3. Peer Review & Physician Accountability

• Oversee fair, transparent, and effective peer review processes.
• Promote a culture of professionalism, accountability, and continuous improvement.
• Support physician performance management in collaboration with Department Chairs and medical staff leadership.
• Collaborate with quality, legal, risk, and human resources to ensure adherence to applicable laws, regulations, bylaws, and professional standards.
• Ensure appropriate follow-up and resolution of physician quality or conduct concerns.

4. Physician Leadership & Medical Staff Engagement

• Lead physician engagement efforts, including communication, conflict resolution, change management, and partnership-building across employed and independent members of the medical staff.
• Strengthen alignment and engagement across employed and independent physicians.
• Serve as a liaison between administration and organized medical staff leadership.
• Support physician leadership development and succession planning initiatives.
• Foster trust, collaboration, and physician engagement across the enterprise.

5. Enterprise Collaboration & Clinical Consistency

• Partner with the Chief Clinical Officer and Medical Group leadership to ensure alignment between governance structures and operational priorities.
• Support enterprise initiatives related to quality, patient safety, and clinical standardization.
• Advance system-wide consistency in physician governance and professional practice expectations.

Key Relationships

• Executive Vice President & Chief Physician Executive
• Chief Clinical Officer
• President, Luminis Health Medical Group
• Chief Legal Officer
• Chief Compliance Officer
• Department Chairs & Executive Medical Directors
• Vice President, Quality & Patient Safety
• Human Resources Leadership

Qualifications

Education & Certification

• MD or DO required.
• Completion of ACGME-accredited residency required.
• Current Board Certification required.
• Eligible for medical licensure in Maryland.
• Advanced degree such as MBA, MPH, MHA, or equivalent is strongly preferred.

Experience

• Minimum of 7–10 years of progressive physician leadership experience.
• Demonstrated experience in medical staff governance, credentialing, peer review, and physician leadership.
• Strong understanding of accreditation, regulatory, and compliance requirements.
• Experience working collaboratively with organized medical staff structures.
• Demonstrated ability to navigate sensitive physician relations and governance matters.