Job Summary:
The Director of Accreditation & Licensure reports to the Exec. Director Accreditation and Licensure. The Director provides expertise and consultation on The Joint Commission (TJC); Georgia Department of Human Resources (DHR); Center for Medicare and Medicaid Services (CMS); and other regulatory standards and requirements and related processes. This position is responsible for development and provision of strategies to support continuous survey readiness (CSR) activities, link CSR to safety, and compliance across the healthcare system. The Director keeps Senior Leadership informed of Wellstar's survey readiness status as well as new/revised regulatory requirements and the impact on the organization. He/she ensures routine self-assessment of compliance with various standards/regulations, development of action plans, review and revision of related policies and procedures and submission of Periodic Performance Reviews to the TJC. The Director supports the System during various survey/review activities, i.e., TJC survey, State visits. Ensure timely submission by all of recommendations for improvement and deficiencies identified by outside agencies.Core Responsibilities and Essential Functions:
Oversees Survey Readiness Activities* Develops strategies to support continuous survey readiness activities across the system* Provides consultation on strategies to support Disease Specific Certifications* Identifies key metrics to be submitted to system to monitor survey readiness activities* Monitors and tracks areas of non-compliance; facilitates barrier removal* Oversees the process for periodic compliance assessment utilizing V-Survey* Routinely reports survey readiness to Sr. Leadership* Develops strategies to incorporate survey readiness training in leadership on boarding processes and to hardwire skills needed to sustain a state of continuous survey readiness* Oversees that JC Periodic Performance Reviews are completed as required* Coordinates mechanism to audit improvements for effectiveness and sustainability* Monitors and ensures timely submission of recommendations for improvement and deficiencies identified by outside agenciesDirects the Standard Policy and Procedure Process* Develops and implements a reliable process for periodic review and revision of policies and procedures* Educates writers on policy and procedure development and formatting, ensuring product reflects current requirements* Directs the approval, implementation and posting processSupports Accreditation Activities Across the System* Provides support to site accreditation in all aspects as needed* Supports training and ongoing education of System and/or Site Function Leaders* Develops and provides education and mentoring to new employees as requested* Supports the system during various survey preparation/review activities* Develops prn pool of staff to support system as neededServes as content expert and consultant to Wellstar Health System* Monitors current and future state of regulatory requirements and related processes* Research new and/or revised standards; provides guidance to the organization* Collaborates with other organizations; shares experiences and lessons learned* Educates leadership on new and/or revised standards and processes and the potential impact on the organization* Drives continuous survey readiness through leading The Joint Commission Steering Committee* Serves as liaison between system and TJC; communicates with Standards Interpretation Group (SIG) on questions related to standards and communicates responses across system* Provides budget guidance on survey related activitiesOversees Compliance with TJC Leadership Standards* Facilitates leadership review and assessment of compliance with leadership standards and requirements* Develops and implements action plans to address opportunities for improvement working collaboratively with leadership teamPerforms other duties as assignedComplies with all Wellstar Health System policies, standards of work, and code of conduct.Required Minimum Education:
Bachelor's Degree BS degree in a healthcare related fieldRequired Minimum License(s) and Certification(s):
All certifications are required upon hire unless otherwise stated.

• HCQM - Cert Healthcare Quality Mgt-Preferred within 1 Year

Additional License(s) and Certification(s):
Required Minimum Experience:
Minimum 5 years experience in coordinating regulatory agency survey activities. RequiredRequired Minimum Skills:
Must have strong interpersonal skills, be able to multi-task, be flexible, organization skills to support a multi-component systemtravel between componentsoccasional out of town travel for seminars, etc.

Join us and discover the support to do more meaningful work-and enjoy a more rewarding life. Connect with the most integrated health system in Georgia, and start a future that gives you more.