Quality, Compliance and Accreditation Manager

Job Summary

The Quality, Compliance and Accreditation Manager supports the organization's Quality Improvement, Compliance, Accreditation, and Risk Management activities. Working collaboratively with leadership and program staff, the Manager promotes continuous quality improvement, regulatory compliance, safety, and organizational excellence. Responsibilities include case record reviews, facility and environmental compliance audits, Joint Commission survey readiness, performance improvement initiatives, data analysis, corrective action monitoring, and support for state licensing, payer, and accreditation requirements.

Essential Functions

• Coordinate quality improvement, compliance, accreditation, and risk management activities
• Conduct scheduled and unannounced case record audits for compliance with Joint Commission, state licensing, payer, and organizational standards.
• Conduct facility and environmental compliance rounds assessing Environment of Care, Infection Control, Medication Management, Life Safety, and National Patient Safety Goals.
• In collaboration with the Director of Quality Improvement and Compliance, coordinate Joint Commission survey readiness, mock surveys, tracers, and evidence collection.
• Collect, analyze, trend, and report quality and compliance data.
• Serve as a liaison for licensing inspections, payer audits, and other regulatory reviews as assigned.
• Coordinate survey logistics, documentation, and responses, and escort surveyors during site visits.
• Participate in and/or chair Quality Improvement, Safety, Infection Control, and other assigned committees.
• Prepare committee agendas, minutes, reports, and monitor follow-up activities.
• Coordinate the development, review, revision, implementation, and communication of policies and procedures.
• Serve as Quality Improvement representative for assigned programs.
• Develop audit tools, dashboards, scorecards, and monitoring systems.
• Assist with Plans of Correction and performance improvement initiatives across the organization.
• Monitor completion and effectiveness of corrective actions.
• Review incidents, sentinel events, and risk data; investigate and complete Root Cause Analyses.
• Provide education regarding regulatory and accreditation standards and documentation requirements.
• Monitor regulatory and accreditation changes and communicate updates.
• Collaborate with program staff, operational and clinical leadership to improve quality and compliance.
• Perform other duties as assigned.