Accreditation Program ManagerThe 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 a 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 licenseSkills: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 detailPrincipal 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 issuesManages (and develops as needed) the hospital's triennial survey preparation plan, including but not limited to mock surveys, documentation review, and educationMonitors changes in regulatory and accreditation standards and ensures timely communication to stakeholdersServes 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 documentationLeads 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 staffCollaborates 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 minutesProvides leadership updates regarding accreditation readiness status, risks, and post-survey results.Maintains oversight 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 minutesLeadership responsibilities include:Oversees Accreditation SpecialistCompletes payroll, time and attendanceImplements corrective actions as neededCompletes and administers performance evaluationsTracks employee position requirements and ensures the employee file is completeWhen searching for a new candidate, responsible for the interview process and evaluation of candidate(s)Oversees (and administers as needed) orientations and competenciesCoaches and mentors staffAll Role Must Follow GBMC Values:RespectTreats others with fairness, kindness, and respect for personal dignity and privacyListens and responds appropriately to others' needs, feelings, and capabilitiesExcellenceMeets and/or exceeds customer expectationsActively pursues learning and self developmentPays attention to detail; follows throughAccountabilitySets a positive, professional example for othersTakes ownership of problems and does what is needed to solve themAppropriately plans and utilizes required resources for various job dutiesReports to work regularly and on timeTeamworkWorks cooperatively and collaboratively with others for the success of the teamAddresses and resolves conflict in a positive waySeeks out the ideas of others to reach the best solutionsAcknowledges and celebrates the contribution of othersEthical BehaviorDemonstrates honesty, integrity and good judgmentRespects the cultural, psychosocial, and spiritual needs of patients/families/coworkersResultsEmbraces change and improvement in the work environmentContinuously seeks to improve the quality of products/servicesDisplays flexibility in dealing with new situations or obstaclesAchieves results on time by focusing on priorities and manages time efficientlyPay Range$79,517.04 - $143,130.67Final salary offer will be based on the candidate's qualifications, education, experience and alignment with our organizational needs.Equal Employment OpportunityGBMC HealthCare and its affiliates are Equal Opportunity employers. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity and expression, age, national origin, mental or physical disability, genetic information, veteran status, or any other status protected by federal, state, or local law.