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A cover letter is required for consideration for this position and should be attached as the first page of your resume. The cover letter should address your specific interest in the position and outline skills and experience that directly relate to this position.

Job Summary

Provides administrative management, leadership, and direction of the Credentialing Office (Medical Staff Services (MSS)) and initiatives to ensure ongoing accreditation by The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), National Commission for Quality Assurance (NCQA), URAC, state and federal regulators, and all managed care payers. Manages and coordinates all appointment/reappointment, and credentialing and privileging processes within Michigan Medicine, ensuring strict compliance with applicable rules and regulations of the accrediting bodies. Works closely and effectively with the Administrative Director of MSS, the Chief of Staff, hospital leadership, clinical departments, Medical School, and the Office of General Counsel in order to provide required services.

Ability to analyze, compare, and evaluate various courses of action, and have the authority to make independent decisions on matters of significance, free from immediate direction, within the scope of their responsibilities. Primary activities and decision making authority are predominantly performed independently affecting business operations to a substantial degree.

Continually reviews processes to assess overall compliance with accrediting bodies; develops and implements policies, procedures and data collection to facilitate this ongoing effort. Works closely with clinical departments, and physician faculty to identify and implement supportive or corrective processes to manage accreditation requirements.



  • Provide leadership to MSS Staff
  • Oversight for performance improvement initiatives and activities
  • Set and maintain budget/financial objectives
  • Approval of expenditures
  • Long-term maintenance and support for affiliate credentialing, health plan audits, and vendor contracts
  • eHealth credentialing and privileging initiatives
  • New privilege/new technology requests
  • Represent MSS at routine and ad hoc committees



  • Manage day-to-day operations of permanent staff that include credentialing specialists, database administrator, OPPE programmer, project manager, and administrative assistant
  • Makes decisions on hiring, promotions, disciplinary action
  • Manage and monitor staff workload
  • Monitors staff performance
  • Developing and managing staff performance improvement plans
  • Set team goals
  • Procedure manual development and ongoing maintenance
  • Staff performance metric development and reporting
  • Timekeeping


Performance and Process Improvement:

  • Leads and participates in LEAN weekly huddles
  • Use Lean in Daily Work methodology for process improvement
  • Monitors key metrics that drive performance
  • Monitoring performance goals of direct reports
  • Maintaining and monitoring all staff metrics at the individual and team level
  • Establishes targets and thresholds for performance
  • Engages staff in improving performance
  • Develops and documents standard work for all important business processes

Policy Management:

  • Creation, maintenance, and updates of Medical Staff Services policies
  • Advises on related bylaw revisions specific to crednetialing and privileging
  • Advises on policy interpretation
  • Collaborates with others on development of health system wide policies
  • Medical Staff policy management (coordinating with external departments)

Credentialing and Privileging

  • Internal file audit for accuracy and compliance with regulatory requirements
  • Currently leads initiatives to move to a paperless credentialing process
  • Staffing Michigan Medicine Credentialing Committee, coordinating agenda setting and managing follow up items
  • Document management for all MSS forms
  • 10% effort for delegated credentialing under affiliate contract for UM practitioners practicing at affiliate sites
  • Privileging document development and oversight of ongoing document maintenance
  • Manages appropriate escalation of findings during the credentialing process, coordinating with the Administrative Director for MSS, the Chief of Staff, Department Chair, or Service Chief when appropriate

Regulatory Readiness

  • Coordinates delegated payer audits for 15 contracted health plans
  • Participation in TJC, CMS, and state licensing surveys
  • Works closely with the Office of Clinical Affairs on identified issues (the formal Medical Stafff Office)
  • Managing performance improvement plans/corrective action plans if needed
  • Ensures appropriate disciplinary action and sanctions are reported to outside agencies

Affiliations, Acquisitions, and Mergers

  • Acts as MSS lead for due diligence review specific to credentialing and privileging to identify gaps and best practices for new healthcare acquisitions, contracts, or affiliations
  • Maintains ongoing due diligence with affiliates ensuring alignment with current policies and procedures for credentialing and privileging 
  • Development and maintenance of delegated credentialing contracts and telemedicine agreements
  • Long-term maintenance of affiliate relationships
  • Representation on affiliate credentialing committees

Finance, Budget, and Contracting

  • Evaluates key financial, budgetary and other metrics related to operations
  • Provides information, trends or other conditions that may affect operations or budget planning
  • Participates in the development of FTE budgetary expenses, operational expenses and capital budgets in coordination with the Administrative Director and Office of Clinical Affairs
  • Manages current vendor contracts for MSS
  • MSS lead for delegated facility and payer credentialing contract development and review


  • Approximately 10% travel for offsite meetings and conferences

Required Qualifications*

  • Bachelor's degree in Business, Public Health, Administration or other related field, or an equivalent combination of education and experience
  • Considerable knowledge of CMS, TJC, NCQA, and URAC rules and regulations as they relate to hospital accreditation, credentialing, and privileging
  • Ability to commit to and meet deadlines, while not compromising quality
  • Must be extremely detail oriented and able to handle multiple projects, prioritizing workload to maximize efficiency
  • Outstanding verbal and written communication skills, as well as advanced organizational skills
  • Strong record of working effectively with staff in a diverse environment
  • Strong analytical thinking

Desired Qualifications*

  • Master's degree in Business, Public Health, Administration or other related field, or an equivalent combination of education and experiencemed
  • 3-6 years’ experience in management with supervisory responsibilities
  • CPMSM (Certified professional Medical Staff Management) certification from NAMSS or certified within five years of employment
  • Trained in LEAN principles for healthcare
  • Experience with CACTUS from symplr® software
  • Knowledge and understanding of the University of Michigan Health System policies and procedures
  • Experience in an academic medical center
  • Experience with paperlass credentialing

Work Locations

2500 Green Road. Ann Arbor, MI

Background Screening

Michigan Medicine conducts background screening and pre-employment drug testing on job candidates upon acceptance of a contingent job offer and may use a third party administrator to conduct background screenings.  Background screenings are performed in compliance with the Fair Credit Report Act. Pre-employment drug testing applies to all selected candidates, including new or additional faculty and staff appointments, as well as transfers from other U-M campuses.

Application Deadline

Job openings are posted for a minimum of seven calendar days.  The review and selection process may begin as early as the eighth day after posting. This opening may be removed from posting boards and filled anytime after the minimum posting period has ended.

U-M EEO/AA Statement

The University of Michigan is an equal opportunity/affirmative action employer.


U-M COVID-19 Vaccination Policy

COVID-19 vaccinations are now required for all University of Michigan students, faculty and staff across all three campuses, including Michigan Medicine.  This includes those working or learning remotely.  More information on this policy is available on the Campus Blueprint website or the U-M Dearborn and U-M Flint websites.