Job Title:
Director - Accreditation
Job ID:
James Cancer Hospital/CCC
Accreditation & Compliance
Full/Part Time:
FTE %:
Salary Range Min:
Salary Range Max:

Position summary

Director - Accreditation (Job Opening 436990) - Scope of Position: This position directs the hospital's operations & activities to comply with all accreditation, regulation, & licensing requirements for all health care sites & services across the continuum. Translates various accrediting, regulatory & licensing agency requirements into action plans to achieve positive survey/audit reviews and implements systems to effectively monitor compliance to standards & to implement new processes to meet new requirements. The director serves as a professional resource throughout the health system to interpret Joint Commission standards, Ohio Department of Health, Center for Medicare regulations and other accrediting agencies applicable to the hospital and ambulatory environment. Responsible for the appropriate development and review of all hospital based policies to assure alignment with Joint Commission, Department of Health and CMS regulations. Assists other departments to design, coordinate, implement and evaluate their internal processes and policies to assure alignment with Joint Commission, Department of Health and CMS regulations. Position Summary: The Director of Accreditation and Policy is responsible for management of departmental operations, evaluation of manager and employee performance, demonstrating customer satisfaction and strategic and operational planning and program development. The director serves as a leader and mentor both within the department and throughout the medical center. The director demonstrates knowledge of governmental & other regulatory standards, requirements, & guidelines related to quality improvement, such as The Joint Commission, NCQA, Federal HMO Act, CMS Conditions of Participation, OSHA, FDA, HIPAA & Medical & Medicare regulations & standards. Has a strong working knowledge of ongoing monitoring techniques (including criteria development & statistical analysis); medical care delivery in hospital & outpatient settings; total quality management principles, tools, & techniques. Must have effective communication, negotiation and leadership skills.

Education and experience

Masters degree in nursing or health care related field, or an equivalent combination of education and experience is required. Minimum 3 to 5 years of experience in patient care and or hospital management, including but not limited to regulatory & licensing, accreditation, performance improvement, risk management and quality assurance in an acute care hospital. Current experience (within the last three years) preferred with regulatory survey process and development of regulatory plans of correction/action plans. Current Ohio Registered Nurse License, if applicable. Extrmely knowledgable of TJC, CMS, ODH and HIPAA standards and regulations.