Job Title:
Assoc Director - Accreditation
Job ID:
Shared Services
Hospitals Administration
Full/Part Time:
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Position summary

Assoc Director - Accreditation (Job Opening 443939) - Scope of Position:
The Associate Director of Accreditation is responsible for implementing the administrative aspects of the accreditation strategies developed by the Director and Associated Executive Director of University Hospital / Ross Heart Hospital Administration. This will include the monitoring of operationalizing policies and procedures, conducting regulatory audits and drills, monitoring compliance and assisting with continual survey readiness. The Associate Director of Accreditation will work directly with members of the faculty and staff to assure provision of high quality patient care while ensuring regulatory compliance of University Hospital, The Ross Heart Hospital, Dodd Hall, Harding Hospital, and the associated ambulatory sites (Hereafter referred to as University Hospital accreditation). The position also works collaboratively with the Accreditation Program Director for University Hospital East (UHE).

Position Summary:
The Associate Director of Accreditation is responsible for the day-to-day operations of University Hospital accreditation. The Associate Director will:
- Review and analyze laws, regulations, and accreditation standards to determine operational impact
- Prepare documents and reports related to policies and procedures, accreditation, and regulatory functions
- Monitor University Hospital compliance for accreditation to include The Joint Commission, CAP, ODH, CMS, and others as determined appropriate.
- Distributes pertinent information by working closely with UHE and The James Accreditation.

Education and experience

Masters degree in health related field or equivalent combination of education and experience. Acute Care Clinical background highly desirable.