The Senior Director, Medical Affairs Office (MAO) provides leadership for the design, implementation, and ongoing operations of the enterprise Medical Affairs Office. This role serves as the central authority for physician and advanced practice provider (APP) governance, credentialing, and performance oversight, ensuring consistency, compliance, and alignment across Memorial Health.

The Senior Director, Medical Affairs Office leads the MAO as the “single source of truth” for physician and APP matters system-wide, partnering closely with executive leadership, physician leaders, and cross-functional teams to drive clinical excellence, regulatory compliance, and provider alignment.

Education:

• Master’s degree in Healthcare Administration, Business Administration, or related field required

Licensure/Certification/Registry:

• Lean Six Sigma Green belt preferred

Experience:

• 10+ years of progressive leadership in medical staff affairs, credentialing, or clinical enterprise operations
• Demonstrated experience leading enterprise-level governance
• Experience with accreditation (Joint Commission, NCQA) and regulatory environments

Other Knowledge/Skills/Abilities:

• Achievement Orientation: Possesses a concern for surpassing a standard of excellence, either by striving for improvement of one’s own performance, outperforming others, or by setting goals to achieve something that has not been previously done.
• Analytical Thinking: Ability to understand a situation, issues or problem by breaking it into smaller pieces, or tracking its implications in a step-by-step way.  
• Change Leadership: Ability to energize stakeholders and sustain their commitment to changes in approaches, processes, and strategies.
• Innovative Thinking: Ability to apply complex concepts, develop creative solutions, or adapt previous solutions in new ways for breakthrough thinking in the field.
• Organization Awareness: Ability to understand and learn the formal and informal decision-making structures and power relationships in an organization or industry, including the ability to identify who the real decision makers are and the individuals who can influence them, and to predict how new events will affect individuals and groups within the organization.  Advanced knowledge of the healthcare delivery system, including regulations, trends, policies and procedures.
• Relationship and Network Development: Ability to establish, build and sustain professional contacts for the purpose of building networks of people with similar goals that support similar interests

1. MAO Strategy, Design & Execution

Lead development and operationalization of the Medical Affairs Office aligned to the Physician Enterprise model. Translate MAO charter, governance, and operating model into execution (policies, workflows, decision rights). Partner with executive leadership to align MAO strategy with enterprise clinical and operational priorities. Serve as primary liaison to external partners supporting MAO design and implementation.

2. Medical Staff Governance & Enterprise Oversight

Support coordinated governance for all physicians and APPs across Memorial Health (employed and partnered). Support enterprise-level physician governance councils and committee structures. Ensure consistent application of Medical Staff bylaws, policies, and governance frameworks.

3. Credentialing, Privileging & CVO Oversight

Oversee enterprise credentialing and privileging (initial appointment, reappointment, and privileges). Lead development and implementation of a Central Verification Office (CVO) model. Standardize credentialing processes, SLAs, and performance metrics across the enterprise. Ensure audit readiness and regulatory compliance.

4. Provider Performance, Quality & Peer Review

Oversee enterprise OPPE and FPPE programs for physician and APP performance evaluation. Lead development and execution of structured peer review frameworks and case management processes. Ensure enterprise quality scorecards are developed and utilized across all clinicians. Partner with clinical and quality leaders to align provider performance with system priorities.

5. Physician & APP Lifecycle (Non-Employment Scope)

Oversee non-clinical aspects of provider lifecycle including: Medical director contracts. On-call contracts and schedules. Governance participation and leadership development. Ensure standardized processes and tracking for all non-employed and employed physicians and APPs

6. Physician Engagement, Leadership Development & Wellness

Lead enterprise programs for medical staff leadership development. Oversee clinician wellness initiatives in partnership with HR and physician leaders. Support physician engagement strategies and alignment with system goals.

7. Cross-Functional Integration

Partner with HR, Finance, and Legal to integrate MAO activities with enterprise functions. Align credentialing, compliance, contracting, and reporting processes across workstreams. Ensure regulatory compliance (OIG, Stark, Joint Commission, CMS) and coordination with Legal.

8. Operational Excellence & Infrastructure

Build and lead MAO support personnel model and operating standards. Develop dashboards and reporting infrastructure (credentialing turnaround, compliance, quality metrics). Drive continuous improvement and standard work across MAO functions. Ensure readiness for accreditation and regulatory audits.

9. Leadership & Team Development

Build and lead a high-performing MAO leadership team. Oversee organizational design, staffing, and capability development. Foster a culture of accountability, service excellence, and continuous improvement.

10. Embodies the Memorial Health System Values of Safety, Integrity, Quality, and Stewardship that support our mission and vision:

• SAFETY: I put safety first. I speak up, without fear, on matters of patient and colleague safety. I take action to create an environment of zero harm.
• INTEGRITY: I respect others and show compassion. I behave honestly and ethically. I am accountable for our attitude, actions and health.
• QUALITY: I advance my knowledge and skills. I seek continuous improvement. I deliver evidence-based care that leads to excellence in outcomes.
• STEWARDSHIP: I use resources wisely and maintain financial stability. I work to coordinate care and services across the health system. I promote healthier communities.