Director, Credentialing & Accreditation

City of Rochester · $109,000–$163,600 (stated in the posting)

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As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

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Essential Functions:

• Provides operations leadership and oversight of enterprise credentialing, recredentialing, primary source verification, clinical privileging, and ongoing monitoring activities to ensure applications and files are complete, accurate, securely maintained, and advanced through review and approval within established timelines and in accordance with medical staff bylaws, organizational policies, contracts, and applicable regulatory and accreditation standards. Assists department senior leadership with operational planning, resource allocation, vendor and contract oversight, budget monitoring, risk management, and departmental communications. Provides coverage for area leaders as assigned and has delegated authority for routine operational decisions within the approved scope.
• Leads, coaches, and evaluates managers, supervisors, and other assigned staff responsible for initial appointments, reappointments, privileging, credentials verification, certification/accreditation, and related functions. Establishes clear performance expectations, reviews workload and staffing needs, supports succession and retention planning, and ensures corrective action and performance improvement plans are implemented when required.
• Directs operational readiness and ongoing compliance with The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), New York State Department of Health (DOH), Occupational Safety and Health Administration (OSHA), National Practitioner Data Bank (NPDB), delegated commercial payer requirements, and other applicable standards. Interprets new and revised requirements and coordinates their implementation across departmental workflows.
• Oversees preparation for and response to accreditation surveys, regulatory reviews, delegated credentialing audits, and internal compliance assessments. Reviews evidence, validates corrective action plans, monitors remediation, and serves as a Medical Staff Services representative during surveys and audits. Coordinates and provides final operational review of NCQA accreditation and reaccreditation submissions prepared by assigned staff, subject to leadership approval.
• Leads the development, review, approval routing, implementation, and maintenance of credentialing, privileging, reappointment, ongoing monitoring, and accreditation policies and procedures. Ensures policies remain aligned across hospitals and contracted entities while reflecting differences required by governing documents, contracts, or regulations. Provides education and guidance to staff and stakeholders regarding medical staff bylaws, policies, and regulatory requirements. Oversees the development, standardization, periodic review, and system maintenance of specialty-specific, criteria-based privilege forms. Collaborates with department chairs, clinical chiefs, medical staff leaders, quality, legal counsel, and hospital leadership to ensure privilege criteria reflect current practice, organizational capability, regulatory requirements, and accreditation standards.
• Provides oversight of Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) processes, including policy alignment, completion monitoring, documentation standards, escalation of deficiencies, and incorporation of required information into appointment and reappointment decisions. Partners with clinical and quality leaders to resolve gaps and improve consistency across facilities. Oversees the credential and privilege review process and the preparation of files, agendas, recommendations, and supporting documentation for Credentials and Privileges Review Committees, Medical Executive Committees, and governing boards. Ensures approvals, minutes, actions, emergency or temporary privileges, mid-cycle privilege changes, and resignations are accurately documented, communicated, and entered into the credentialing system.
• Reviews and guides the management of complex, high-risk, or adverse credentialing matters, including malpractice history, sanctions, complaints, gaps, professional conduct concerns, quality-of-care information, licensure or certification issues, and NPDB reports. Escalates significant matters to the Senior Director, Chief Medical Officer, legal counsel, compliance, quality leadership, or medical staff leadership as appropriate while preserving confidentiality and due process. Directs ongoing monitoring of practitioner expirables and compliance requirements, including licenses, DEA registrations, board certifications, health requirements, sanctions, exclusions, NPDB Continuous Query reports, and other required credentials. Ensures timely follow-up, escalation, suspension, or other action in accordance with policy and governing documents.
• Builds effective relationships with physicians, advanced practice providers, department chairs, clinical chiefs, medical staff officers, hospital executives, affiliated organizations, contracted clients, and internal partners. Serves as a subject matter expert and escalation resource for credentialing, privileging, accreditation, and medical staff compliance questions, and represents Medical Staff Services on committees and enterprise initiatives as assigned.
• Maintains professional knowledge through participation in national and state associations, educational programs, conferences, and regulatory updates. Evaluates emerging practices and technologies and recommends changes that enhance compliance, efficiency, data quality, staff capability, and stakeholder service.
• Other duties as assigned.

Minimum Education & Experience:

• Bachelor's degree in business, health care administration, health information management, or a related field and 6 years of progressively responsible experience in medical staff services, credentialing, privileging, and accreditation required.
• Or equivalent combination of education and experience.
• Master's degree preferred.
• Demonstrated experience supporting regulatory surveys, accreditation reviews, delegated credentialing audits, policy development, corrective action plans, and sustained compliance monitoring required.
• Experience with OPPE/FPPE, criteria-based privilege development, medical staff committee and governing board processes, and complex credentialing issue resolution preferred.

Knowledge, Skills & Abilities:

• Advanced knowledge of medical staff credentialing and privileging principles and applicable TJC, CMS, NCQA, DOH, OSHA, NPDB, and delegated credentialing requirements required.
• Demonstrated ability to establish performance measures, analyze operational data, improve workflows, manage change, and lead teams through organizational or technology transformation required.
• Excellent written, verbal, interpersonal, and presentation skills, with the ability to build trusted relationships and communicate effectively with practitioners, executives, clinical leaders, regulators, auditors, staff, and external partners required.

Licenses and Certifications:

• Certified Professional Medical Services Management (CPMSM) preferred.
• Certified Provider Credentialing Specialist (CPCS) preferred.
• Attainment of an applicable NAMSS certification within a timeframe established by the organization preferred.

The University of Rochester is committed to fostering, cultivating, and preserving an inclusive and welcoming culture to advance the University’s Mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion, creed, sex, sexual orientation, citizenship status, or any other characteristic protected by federal, state, or local law (Protected Characteristics). This commitment extends to non-discrimination in the administration of our policies, admissions, employment, access, and recruitment of candidates, for all persons consistent with our values and based on applicable law.

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