Coordinates the interdisciplinary efforts to prepare for all accreditation and certification efforts managed by the Quality Services Department. Oversees the Survey Readiness Program for the organization. Works with all organizational divisions and departments to ensure that all accreditation and certification standards, as well as all regulatory requirements are met. Coordinates the policy approval process for all policies in the Blount Memorial Systems Manual and ensures that policies are composed and approved within alignment of regulatory requirements. Conducts activities within the organization that develop and maintain processes that result in high quality and safe care of patients and achieves a consistent survey-ready status in the facility. Uses the electronic policy system for the organization and assists parties responsible for policy oversight with the use of this system. Facilitates the review and update of all Blount Memorial Systems Manual. Facilitates and supports organizational meetings and work efforts to obtain accreditation, certification, and strategic quality goals as set forth by Executive Group and the Board of Directors. Oversees the management of documents that pertain to patient medical records, such as downtime order forms. Assists Quality Management team members with other duties as requested.

Education and/or experience: Associates or Bachelor's degree preferred with minimum of 2 years experience in healthcare setting. Experience in survey preparedness, interpreting accreditation and certification standards preferred. Previous experience in policy development, with working knowledge of regulatory guidelines and requirements also preferred.