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. The Accreditation Program Manager is the point of contact for all announced and unannounced surveys and serves as the liaison between the surveyors and leadership. This role collaborates with clinical and operational leaders to identify gaps, guide corrective action planning, and integrate regulatory/accreditation readiness into daily operations and Quality/Patient Safety initiatives. The role also oversees the policy management system and process. The Accreditation Program Manager serves as the hospital's subject matter expert on regulatory and accreditation standards and promotes and culture of safety, quality, and regulatory compliance throughout the hospital. The Accreditation Program Manager oversees the Accreditation Specialist.
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.
Licensures, 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 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
- Experience facilitating interdisciplinary teams and working with clinical and operational leaders
- Strong organizational skills and attention to detail
Principal Duties and 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
- Monitors changes in regulatory and accreditation standards and ensures timely communication to stakeholders
- 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
- Leads 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.
- Maintains oversite for the policy management system and ensures policies meet regulatory and accreditation requirements.
- Prepares for and facilitates the hospital's Policy Advisory Committee (PAC) including agenda and minutes
Leadership responsibilities include:
- Oversees Accreditation Specialist
- Completes payroll, time and attendance
- Implements corrective actions as needed
- Completes and administers performance evaluations
- Tracks employee position requirements and ensures the employee file is complete
- When searching for a new candidate, responsible for the interview process and evaluation of candidate(s)
- Oversees (and administers as needed) orientations and competencies
- Coaches and mentors staff
All Role Must Follow GBMC Values:Respect
- Treats others with fairness, kindness, and respect for personal dignity and privacy
- Listens and responds appropriately to others' needs, feelings, and capabilities
Excellence
- Meets and/or exceeds customer expectations
- Actively pursues learning and self development
- Pays attention to detail; follows through
Accountability
- Sets a positive, professional example for others
- Takes ownership of problems and does what is needed to solve them
- Appropriately plans and utilizes required resources for various job duties
- Reports to work regularly and on time
Teamwork
- Works cooperatively and collaboratively with others for the success of the team
- Addresses and resolves conflict in a positive way
- Seeks out the ideas of others to reach the best solutions
- Acknowledges and celebrates the contribution of others
Ethical Behavior
- Demonstrates honesty, integrity and good judgment
- Respects the cultural, psychosocial, and spiritual needs of patients/families/coworkers
Results
- Embraces change and improvement in the work environment
- Continuously seeks to improve the quality of products/services
- Displays flexibility in dealing with new situations or obstacles
- Achieves results on time by focusing on priorities and manages time efficiently
Pay Range$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.
