Director, Credentialing & Accreditation

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.

Job Location (Full Address):135 Corporate Woods, Rochester, New York, United States of America, 14623

Opening:

Worker Subtype:

Regular Time Type:

Full time Scheduled Weekly

Hours:

40

Department:910397 URMC Medical Staff Services

Work Shift:

UR
- Day (United States of America)
Range:

UR URG 116

Compensation Range:$ - $The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job's compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations.

Responsibilities:

Provides operational and regulatory leadership for enterprise credentialing, recredentialing, clinical privileging, accreditation, and medical staff compliance activities across UR Medicine hospitals, affiliated organizations, and contracted clients. Translates direction from senior leadership into consistent operational plans, performance expectations, policies, and controls that support timely practitioner onboarding, patient safety, regulatory compliance, and reliable provider data. Directly oversees credentialing, privileging, certification/accreditation, and related operational managers and serves as the primary escalation point for complex files, compliance concerns, and cross-functional issues.

Partners with medical staff leaders, hospital administration, quality, compliance, legal counsel, information technology, payer enrollment, and affiliated organizations to standardize processes, improve performance, and maintain readiness for regulatory surveys and delegated credentialing audits. Serves as the principal operational backup for credentialing, privileging, and accreditation matters.

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,…