Quality, Compliance and Accreditation Manager

Responsibilities

• Coordinate quality improvement, compliance, accreditation, and risk management activities
• Conduct scheduled and unannounced case record audits for compliance with Joint Commission, state licensing, payer, and organizational standards
• Conduct facility and environmental compliance rounds assessing Environment of Care, Infection Control, Medication Management, Life Safety, and National Patient Safety Goals
• Collaborate with the Director of Quality Improvement and Compliance, coordinate Joint Commission survey readiness, mock surveys, tracers, and evidence collection
• Collect, analyze, trend, and report quality and compliance data
• Serve as a liaison for licensing inspections, payer audits, and other regulatory reviews as assigned
• Coordinate survey logistics, documentation, and responses, and escort surveyors during site visits
• Participate in and/or chair Quality Improvement, Safety, Infection Control, and other assigned committees
• Prepare committee agendas, minutes, reports, and monitor follow-up activities
• Cookordinate the development, review, revision, implementation, and communication of policies and procedures
• Serve as Quality Improvement representative for assigned programs
• Develop audit tools, dashboards, scorecards, and monitoring systems
• Assist with Plans of Correction and performance improvement initiatives across the organization
• Monitor completion and effectiveness of corrective actions
• Review incidents, sentinel events, and risk data; investigate and complete Root Cause Analyses
• Provide education regarding regulatory and accreditation standards and documentation requirements
• Monitor regulatory and accreditation changes and communicate updates
• Collaborate with program staff, operational and clinical leadership to improve quality and compliance
• Perform other duties as assigned

Qualifications

• Bachelor’s degree in a healthcare-related field or equivalent experience
• Minimum 5 years of experience in quality improvement, compliance, accreditation, and risk management
• Experience with Joint Commission standards and accreditation processes
• Strong analytical and problem-solving skills
• Excellent written and verbal communication skills
• Ability to work independently and as part of a team
• Proficiency in Microsoft Office Suite