The Accreditation Manager is responsible for the development and oversight of Accreditation Services. The Accreditation Services Manager leads the organization with ongoing programs to promote integration of standards and regulations for The Joint Commission (TJC), Division of Health Service Resources (DHSR), and Centers for Medicare Services (CMS). This individual serves as a key resource for knowledge of and compliance with external regulatory requirements.Major Work Activities:
- Assures Manage and supervise staff in the Accreditation Services Department.
- Expert knowledge and interpretation Joint Commission, CMS and Standards.
- Develop and manage departmental budget that apply to the regulatory process.
- Educate leaders across the system on changes in regulatory requirements that affect policies and practices.
- Presentations to larger audiences including Senior leaders.
- Conduct proactive risk assessments throughout the organization to identify areas of opportunities to better meet regulatory requirements and communicate the results to appropriate leadership.
- Coordinate onsite survey processes with regulatory agencies; both announced and unannounced.
- Develop and oversee, with other relevant leaders, changes in policies, procedures and practice to assure compliance with regulatory requirements.
- Coordinate investigations in cited complaints and/or deficiencies and respond to regulatory agencies with required plan of action.
- Coordinate the measurement and analysis of data to ensure that improvements in process for regulatory compliance have been sustained over time.
- Communicate with regulatory agencies via a variety of communication channels.
- Chair the Regulatory Chapter Leader meetings and participates on various committees as appropriate.
- Other duties as assigned.
- Five years of healthcare experience required.
- Three years with regulatory compliance experience preferred.
Masters of Nursing or related degree will consider BSN with progressive accreditation experience and certification.Licensure/Certification:
- Green Belt and/or Lean Six Sigma preferred.
- Certification in Healthcare Accreditation will be required within one year of hire.