Job Description

Position Summary:

The Executive Director of Medical Staff Services provides strategic leadership and executive oversight for all credentialing, privileging, medical staff governance, and medical staff support functions, encompassing all Atlantic Health hospitals, ambulatory sites, and physician enterprises. This role ensures enterprise-wide compliance with the Joint Commission, CMS, NCQA, and applicable state and federal regulations, while optimizing operational performance, standardizing processes, and strengthening collaboration with hospital medical staff leaders, risk, legal, HR, and provider recruitment teams. Reporting to the Chief Clinical Officer, the Executive Director serves as the principal authority and policy leader for credentialing and privileging functions, overseeing the development of a centralized Credentialing Verification Office (CVO), medical staff services teams, and privileging infrastructure to support a culture of patient safety, provider accountability, and operational excellence.

Key Responsibilities:

• Provide system-level strategic leadership for all credentialing and privileging operations, including hospitals and ambulatory locations.
• Ensure system-wide compliance with accrediting bodies (e.g., The Joint Commission, CMS) and licensure boards, and support compliance with NCQA and payer credentialing requirements.
• Create, lead and manage the centralized Credentialing Verification Office (CVO), including team structure, resourcing, performance metrics, and staff development.
• Oversee governance and coordination of Medical Staff Office functions at each hospital, ensuring alignment with medical staff bylaws, rules, and regulations.
• Lead the design, implementation, and continuous improvement of standardized credentialing and privileging policies, procedures, and workflows.
• Partner with the CMO, legal, compliance, HR, and IT teams to manage provider onboarding, recredentialing, privileging, and termination processes.
• Direct the adoption and optimization of CredentialStream credentialing and privileging platform across the enterprise.
• Serve as the executive liaison to Credentials Committees, Medical Executive Committees, chief medical officers and hospital presidents, and committees of the Board of Trustees regarding credentialing issues and risk mitigation.
• Maintain data integrity and ensure robust reporting, analytics, and dashboards for leadership visibility and regulatory preparedness.
• Support and evaluate delegated credentialing contracts and relationships with managed care organizations and insurers, if requested.
• Lead change management and training efforts related to credentialing process improvements or system transitions.
• Ensure the credentialing and privileging infrastructure is responsive, efficient, and aligned with organizational growth and physician recruitment strategies.

Required Qualifications:

Education :

• Bachelor’s degree in healthcare administration, Business, Nursing, or a related field required.

• Master’s degree in healthcare administration (MHA), Public Health (MPH), Business (MBA), or related field strongly preferred.

Experience:

• Minimum 10 years of progressive leadership experience in healthcare credentialing and privileging, with at least 5 years in a senior leadership or system-level role.

• Experience leading credentialing for a large, complex, multi-entity hospital system required.

• Deep understanding of medical staff governance, Joint Commission standards, CMS Conditions of Participation, NCQA requirements, and delegated credentialing processes.

• Significant experience with the CredentialStream platform

Certifications:

• CPMSM (Certified Professional in Medical Services Management) required.

• CPCS (Certified Provider Credentialing Specialist) preferred.

Key Competencies:

• Executive presence with the ability to lead across diverse stakeholders and influence at all levels.

• Advanced knowledge of credentialing software and systems (e.g., Echo, CredentialStream)

• Exceptional analytical, communication, and problem-solving skills.

• Ability to manage complex regulatory requirements and translate them into scalable operational processes.

• Strategic thinker with experience driving enterprise transformation and standardization.

• Proven ability to lead teams through change and performance improvement initiatives.

• High integrity, discretion, and commitment to patient safety and provider quality.

• Ability to negotiate contracts and manage budgets.

Job Tags

Similar Jobs