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Req #: 246350

Department: SCHOOL OF MEDICINE

Job Location Detail: Hybrid/Remote

Posting Date: 05/27/2025

Closing Info:

Open Until Filled

Salary: $10,834 - $13,167 per month

Shift: First Shift

Notes:

As a UW employee, you will enjoy generous benefits and work/life programs. For a complete description of our benefits for this position, please visit our website, click here. (https://hr.uw.edu/benefits/wp-content/uploads/sites/3/2018/02/benefits-professional-staff-librarians-academic-contract-covered-exempt-20250130-a11y.pdf)

As a UW employee, you have a unique opportunity to change lives on our campuses, in our state and around the world. UW employees offer their boundless energy, creative problem-solving skills, and dedication to build stronger minds and a healthier world.

UW faculty and staff also enjoy outstanding benefits, professional growth opportunities and unique resources in an environment noted for diversity, intellectual excitement, artistic pursuits, and natural beauty.

The **Associate Director of Credentialing Quality and Compliance** serves as UW Medicine’s system-wide leader for credentialing compliance, regulatory oversight, and internal audit strategy. This role is essential to protecting the institution’s ability to deliver clinical services by ensuring credentialing practices meet the highest standards of safety, legality, and regulatory integrity. The Associate Director ensures alignment with medical staff bylaws, institutional policy, and complex external standards (e.g., TJC, NCQA, CMS, URAC, DOH) that govern clinicians and hospital operations.

Operating at the intersection of risk mitigation, regulatory interpretation, and performance improvement, the Associate Director leads credentialing compliance across multiple entities. This includes internal audits, policy enforcement, and real-time monitoring of system readiness for external review. This role also drives strategic quality initiatives to proactively identify and address vulnerabilities before they escalate to regulatory findings.

This role leads a team that includes the Senior Credentialing Compliance Manager and the Training and Development Manager. The Senior Credentialing Compliance Manager will supervise Credentialing File Auditors, Credentialing Business Partners, and the Privileging Clinical Support Specialist. The Associate Director partners closely with entity Chief Medical Officers, the UWP Compliance Officer, the Privacy Officer, Risk Managers, the Director of Regulatory Affairs, and legal counsel, serving as the Office of Medical Staff Appointment’s primary resource for interpreting policy, responding to audit inquiries, and building a resilient, accountable credentialing infrastructure.

**DUTIES AND RESPONSIBILITIES** Management of Regulatory Audits and Compliance (35%)

+ Serve as the primary liaison for all external audits and accreditation reviews (e.g., TJC, DOH, delegated payer audits), representing the Office of Medical Staff Appointments and responding to inquiries from surveyors.

+ The position will respond to inquiries from executive leadership including medical center Chief Medical Officers, Department Chairs and Directors, and senior administrators in central offices such as Finance, HR, and Legal.

+ Lead internal audit activities and oversee audit preparation in collaboration with credentialing leadership to ensure complete, accurate, and current documentation.

+ Identify cross-cutting themes in audit findings and develop strategies for process improvement, mitigation, and prevention.

+ Partner with the Director of Credentialing Services to ensure smooth handoffs between credentialing operations and internal audit/review functions.

+ Collaborate with the Systems Manager and Training and Development Manager to ensure workflows are supported by current technology and embedded in training material and SOPs.

+ Stay informed on evolving regulatory and accreditation standards. Assess operational impact and drive updates to policies, procedures, and workflows as needed.

+ Monitor trends and systemic issues emerging from credentialing committee reviews and performance evaluations (OPPE/FPPE), using insights to drive policy updates, education, and governance enhancements.

+ Uphold confidentiality and ensure compliance with institutional policies and UW Medicine bylaws, especially when managing sensitive or adverse regulatory findings.

+ Translate regulatory standards and accreditation requirements (TJC, NCQA, CMS, URAC, DOH) into clear, actionable policies and operational workflows.

+ Collaborate with legal, risk, and compliance to ensure workflows and organizational credentialing policies remain in compliance.

+ Develop quality monitoring strategies that enable real-time detection of risks or non-compliance and ensure compliance risks are escalated appropriately.

+ Brief senior leadership (e.g., Senior Director, Chief Medical Officers) on audit results, regulatory shifts, and mitigation plans to ensure organizational awareness and alignment.

+ Define the compliance performance metrics for the staff in the Office of Medical Staff Appointments in partnership with the Director of Credentialing Services.

+ Serve as the escalation point for serious compliance issues, working cross-functionally to address potential institutional risk.Strategic Policy Development and Stakeholder Engagement (35%)

+ Lead initiatives focused on quality assurance, risk mitigation, and internal process improvement.

+ Drive the creation and tracking of compliance performance metrics.

+ Direct the annual review and refresh of internal credentialing and privileging policies.

+ Lead policy development and interpretation related to credentialing and privileging. Ensure consistent application across all entities.

+ Collaborate with senior leaders on enterprise efforts to modernize credentialing governance and ensure readiness for system expansion.

+ Partner with medical center Chief Medical Officers, department chairs, and service chiefs to advise on credentialing policies, interpret regulations, and resolve complex compliance issues.

+ Represent the Office of Medical Staff Appointments in institutional forums and committees focused on credentialing quality, accreditation, and regulatory readiness.

+ Keep internal constituents informed of regulatory changes and emerging compliance risks.

+ Collaborate with entity-specific credentials committees and committee chairs to understand service expectations.Leadership and Team Management (20%)

+ Provide strategic oversight and direction for the Senior Credentialing Quality and Compliance Manager, Training and Development Manager, Credentialing Business Partners, Auditors, and the Privileging and Clinician Support Specialist.

+ Establish performance goals, accountability standards, and workload priorities in collaboration with managers to ensure timely, high-quality credentialing services.

+ Monitor staffing ratios, role clarity, and team capacity to ensure the quality team is structured to meet the demands of the Chief Medical Officers and office file volume.

+ Partner with Human Resources and the Senior Director of the Office of Medical Staff Appointments to define new positions, shape hiring and onboarding strategies, and build long-term career pathways for credentialing staff.

+ Advocate for necessary resources (e.g., roles, tools, skills development) that support long-term success in credentialing operations.

+ Foster a culture of quality, accountability, and continuous learning across the Office of Medical Staff Appointments.

+ Establish key performance metrics and implement tracking mechanisms to measure operational effectiveness and staff accountability.Other Duties as Assigned (10%)

+ Perform additional duties and responsibilities as assigned to support office and organizational goals. **MINIMUM REQUIREMENTS**

+ Bachelor’s degree in healthcare administration, business, or a related field. Equivalent experience may substitute for degree requirements.

+ Minimum of 5 years of experience in medical staff services or credentialing leadership roles. **Equivalent education/experience will substitute for all minimum qualifications except when there are legal requirements, such as a license/certification/registration.** **DESIRED QUALIFICATIONS**

+ Master’s degree in public health administration, health administration, business or related field.

+ Certification by the National Association of Medical Staff Services (NAMSS) as a Certified Professional in Medical Staff Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS).

+ Demonstrated expertise in medical staff and allied health professionals credentialing, privileging and accreditation compliance within an academic medical center or large healthcare system.

+ Experience in implementing process improvements or LEAN methodologies to optimize workflows.

+ Proficiency in credentialing software platforms or healthcare IT systems.

+ Strong knowledge of regulatory standards (TJC, NCQA, and CMS).

+ Proven leadership and team management abilities.

+ Excellent communication and interpersonal skills.

+ Proficiency in medical staff credentialing software.

+ Analytical and problem-solving capabilities. **Application Process:** The application process may include completion of a variety of online assessments to obtain additional information that will be used in the evaluation process. These assessments may include Work Authorization, Cover Letter and/or others. Any assessments that you need to complete will appear on your screen as soon as you select “Apply to this position”. Once you begin an assessment, it must be completed at that time; if you do not complete the assessment, you will be prompted to do so the next time you access your “My Jobs” page. If you select to take it later, it will appear on your "My Jobs" page to take when you are access ready. Please note that your application will not be reviewed, and you will not be considered for this position until all required assessments have been completed.

University of Washington is an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, religion, color, national origin, sexual orientation, gender identity, sex, age, protected veteran or disabled status, or genetic information.