Overview
Description
Job Summary: The Accreditation Manager provides Operating Unit (OU) direction, oversight and support for regulatory and accreditation compliance. This role leads accreditation readiness activities and supports multiple certification and licensure programs. The Accreditation Manager partners with OU clinical, operational, and executive leaders to drive sustained readiness, standardization, and continuous improvement aligned with the organization's Always Patient Ready mission. Primary duties and responsibilities: Accreditation & Regulatory Oversight: 1. Provide OU-level oversight for accreditation and regulatory compliance, including The Joint Commission (TJC), State, and Federal agencies. 2. Remain current with accreditation standards, Conditions of Participation, and regulatory requirements; interpret and translate standards into operational expectations. 3. Serve as the primary OU resource for accreditation and regulatory guidance across departments and service lines. Survey Readiness: 1. Plan, lead, and conduct routine tracers and readiness assessments 2. Provide real-time coaching and education. 3. Identify gaps, risks, and trends; develop actionable recommendations and monitor corrective action plans. 4. Support preparation for announced and unannounced accreditation, licensure, and validation surveys. Education, Training & Consultation: 1. Develop and deliver education and training related to accreditation standards, regulatory requirements, and continuous survey readiness 2. Educate leaders and frontline staff on standards interpretation, tracer methodology, and survey expectations. 3. Serve as a consultant to departments on regulatory compliance, process redesign, and risk mitigation. Performance Improvement & Collaboration: 1. Collaborates with leadership to recommend sustainable processes and system improvements to maintain quality metrics and/or accreditation-related objectives that support high reliability and ongoing readiness. 2. Facilitate interdisciplinary workgroups and committees focused on accreditation readiness and regulatory compliance. Reporting & Documentation: 1. Track, trend, and report accreditation readiness activities, tracer findings, and corrective action status. 2. Support regulatory documentation, policy alignment, and evidence management to ensure survey readiness Other Duties as Assigned. Travel: Less than 10% of the time may be required. Work Type: On-site employee Minimum Required Qualifications Education: Bachelor's degree (BA/BS) in a health-related field required. Experience: Five (5) years of experience in a clinical healthcare environment. Experience in clinical operations and/or performance improvement, patient safety, risk management, or quality management. Skills, Abilities & Knowledge Knowledge of Quality Improvement methodologies, group facilitation, project management, and healthcare regulatory and event reporting requirements. Preferred Qualifications Experience: Previous accreditation and/or regulatory readiness experience preferred. Licensure: Licensure as a Registered Nurse in the state of Georgia strongly preferred.
PHYSICAL REQUIREMENTS (Medium): 20-50 lbs; 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 50 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.
ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.
Additional Details
