Accreditation Program Manager

About the role

The Accreditation Program Manager is responsible for ensuring the hospital maintains ongoing readiness for regulatory and accreditation surveys. This role provides leadership, guidance, and subject-matter expertise to clinical and operational teams to lead survey preparation activities and monitor regulatory and accreditation compliance throughout the hospital.

Responsibilities

• Ensures the hospital is survey-ready.
• Works with leaders to ensure that care is provided in accordance with regulatory and accreditation standards, ensuring the provision of high-quality, safe patient care.
• Maintains continuous survey readiness through the supervision of proactive audits, tracers, mock surveys, and monitoring.
• Tracks and trends regulatory and accreditation findings to identify patient safety and system issues.
• Manages (and develops as needed) the hospital’s triennial survey preparation plan, including but not limited to mock surveys, documentation review, and education.
• Maintains oversight for the policy management system and ensures policies meet regulatory and accreditation requirements.
• Serves as the point of contact during all regulatory and accreditation announced and unannounced surveys and provides a designee (e.g., Accreditation Specialist) to coordinate logistics and support during regulatory and accreditation surveys (e.g., surveyor escorts, document gathering, etc.).
• Ensures maintenance of required regulatory and accreditation documentation.
• Led post-survey follow-up including plan of correction development, evidence of compliance submission, and reporting.
• Facilitates corrective action planning with department leaders, ensuring actions are measurable, meaningful, and sustainable.
• Serves as the hospital’s subject matter expert on regulatory and accreditation standards, providing interpretation, guidance, and education.
• Develops and delivers educational resources, training sessions, and communication tools to support current and new hire staff.
• Collaborates with clinical and operational leaders and teams to align regulatory and accreditation requirements with hospital goals and priorities.
• Ensures regulatory and accreditation requirements are integrated into Quality, Patient Safety, Performance Improvement, and Risk initiatives.
• Prepares for and facilitates the Accreditation Readiness Committee (ARC) which includes review of changes to standards, compliance status of current standards, and any required follow-up, including agenda and minutes.
• Provides leadership updates regarding accreditation readiness status, risks, and post-survey results.
• Prepares for and facilitates the hospital’s Policy Advisory Committee (PAC) including agenda and minutes.
• Oversees Accreditation Specialist.
• Completes payroll, time and attendance.
• Completes and administers performance evaluations.
• Tracks employee position requirements and ensures the employee file is complete.
• Oversees (and administers as needed) orientations and competencies.
• Coaches and mentors staff.

Requirements

• Bachelor’s degree in nursing or other clinical field required; Masters preferred.
• 4-6 years of recent experience in a healthcare regulatory or compliance environment.
• Professional clinical license.
• Extensive knowledge of healthcare regulatory and accreditation standards, including Conditions of Participation (CoP); background in healthcare compliance, quality, patient safety and/or performance improvement preferred, clinical background preferred.
• Ability to interpret and translate complex regulations.
• Proficiency in managing compliance documentation and audits.
• Experience developing plans of correction, managing follow-up actions, and submitting evidence of compliance.
• Skilled in facilitating trainings, leading and coordinating mock surveys and tracers, and presenting leadership updates.
• Ability to remain calm and effective during survey activities and time-sensitive situations.
• Experience in policy management.
• Skilled in facilitating interdisciplinary teams and working with clinical and operational leaders.
• Strong organizational skills and attention to detail.

Qualifications

• Education: Bachelor’s degree in nursing or other clinical field required; Masters preferred.
• Experience: 4-6 years of recent experience in a healthcare regulatory or compliance environment.
• Licenses, Certifications: Professional clinical license.
• Skills: Extensive knowledge of healthcare regulatory and accreditation standards, including Conditions of Participation (CoP); background in healthcare compliance, quality, patient safety and/or performance improvement preferred, clinical background preferred. Ability to interpret and translate complex regulationsProficiency in managing compliance documentation and auditsExperience developing plans of correction, managing follow-up actions, and submitting evidence of complianceSkilled in facilitating trainings, leading and coordinating mock surveys and tracers, and presenting leadership updatesAbility to remain calm and effective during survey activities and time-sensitive situationsExperience in policy managementExperience facilitating interdisciplinary teams and working with clinical and operational leadersStrong organizational skills and attention to detail

Benefits

Not specified

Pay

$79,517.04 - $143,130.67 Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.

Schedule

Not specified