York, PA | Nursing | Tracking Code: 77503

Director of Accreditation and Licensure

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Ed Pritchard
Ed Pritchard
Sr. Talent Acquisition Consultant

Job Description:

Under the general supervision of the Vice President WSH Accreditation and Licensure, the Director will be responsible for maintaining compliance with applicable regulatory requirements, accreditation standards, policies, and medical staff bylaws, medical staff rules and regulations and other governing documents. Oversees the management of administrative duties, including hiring, training, policy, and process development for the credentialing area of the Medical Staff Services department.


Duties and Responsibilities


  1. Direct the Medical Staff Services credentialing personnel, prepare and manage the departmental budget
  2. Maintains a comprehensive working knowledge of medico-legal issues, applicable laws, regulatory agency requirements, and standards, particularly in the area of medical staff/provider credentialing.
  3. Possess a high degree of independent judgment, problem-solving and decision-making capabilities, flexibility, ability to lead others, and perseverance
  4. Collaborate with the entity, facility, Medical Staff, and departmental leaders for the alignment of Medical Staff credentialing operational activities with corporate strategic plans and initiatives
  5. Assist in interpreting Medical Staff Bylaws, Rules and Regulations, policies, procedures as relates to the department.
  6. Possess expert knowledge of Medical Staff Services and credentialing procedures
  7. Ability to organize and manage complex projects, implement new processes, and apply standards consistently
  8. Coordinate the implementation of all approved programs, projects, and activities of the department.
  9. Coach, develop, motivate, and engage team members
  10. Serve as a liaison between Medical Staff and the Board
  11. Excellent interpersonal skills to establish and maintain professional relationships with Medical Staff, corporate departments, and entity teams.
  12. Ability to work independently and exercise good judgment
  13. Keep abreast of appropriate regulatory agency requirements related to Medical Staff issues, credentialing, and accreditation and licensure.
  14. Develop and oversee the implementation of corrective action plans to address survey findings.
  15. Provide ongoing reports and updates of existing and potential regulatory compliance issues to the Vice President, senior leadership, hospital Board(s), and other individuals and groups as directed.
  16. Knowledgeable about Lean methodologies and uses Lean Daily Management System tools to implement practical process improvements.
  17. Develop, establish, and implement goals, objectives, and policies and procedures for department and hospital operations, which guide and support the provision of services.
  18. Continuously assess and improve the department's performance.  Maintain appropriate quality control/assessment programs (as applicable).


  • Notes:
    • Other combinations of formal education, training and experience may be considered.


  • Minimum Experience:
    • 5 years experience with Government Regulations, Healthcare and Regulatory Affairs
    • Clinical experience related to Patient Safety
    • Medical Staff organization management preferred, experience with healthcare related regulatory and accreditation requirements, Cactus software experience preferred


  • Minimum Education:
    • Master's Degree in a related field such as Healthcare Administration, Business Administration, or a medico-legal related


  • Required Certification:
    • Current Certified Professional Medical Staff Management (CPMSM) (preferred)
    • Or actively working toward achieving eligibility requirements to sit for CPMSM examination with achievement within one year of meeting eligibility requirements


  • Skills:
    • Skills of Lean methodologies preferred
    • Demonstrated leadership skills and ability to work independently
    • Demonstrated knowledge of health care and regulatory affairs
    • Must have a global view of the WellSpan Health vision and mission
    • Needs to be analytical, inquisitive, persistent and detail-minded
    • Must possess a work ethic that is fair, moral, objective and discreet
    • Project management and computer skills are required.

Fraud Notice: Please be aware of potentially fraudulent job postings on other websites or suspicious recruiting email or text messages that attempt to collect your confidential information. If you are concerned that an offer of employment with WellSpan Health might be a scam, please verify by searching for the job posting on joinwellspan.org or contact us at employment@wellspan.org.

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Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

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