Manager of Accreditation

Job Title: Manager of Accreditation

Client: Healthcare Provider

Location: Kokomo, IN (EST)

Length: 6-month Contract with potential to go full-time

Summary

The Manager of Accreditation is an essential member of the Quality and Population Health team is responsible for leading and coordinating all activities to ensure the organization is fully prepared for accreditation by The Joint Commission (TJC) and NCQA Patient-Centered Medical Home (PCMH). This position serves as the primary liaison between the client and accreditation bodies, ensuring compliance with standards, policies, and procedures while driving a culture of continuous improvement and regulatory readiness.

Key Responsibilities

• Accreditation Preparedness and Compliance
• Oversee and coordinate all activities related to TJC and PCMH accreditation processes.
• Conduct readiness assessments, mock surveys, and tracers to identify areas of non-compliance.
• Develop and implement corrective action plans and monitor progress toward achieving compliance.
• Maintain up-to-date knowledge of accreditation standards, policies, and regulatory requirements.
• Ensure organizational policies and procedures align with accreditation standards and regulatory requirements.
• Collaborate with department leaders to develop, review, and revise policies as Necessary.
• Develop and deliver education and training programs for staff and leadership to promote understanding and compliance with accreditation standards.
• Provide coaching and support to departments to address identified gaps in compliance.
• Ensure accurate documentation of compliance activities, findings, and improvement
• efforts.
• Prepare and submit required reports to accreditation bodies.
• Act as a resource and advisor to leadership and staff on accreditation and compliance matters.
• Foster a culture of continuous improvement by promoting proactive identification and resolution of compliance risks.
• Serve as the primary contact during accreditation surveys and facilitate interactions with surveyors.

Qualifications & Education

• Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field required. Master’s degree preferred.
• RN License is preferred
• Minimum of 5 years of experience in healthcare accreditation, quality assurance, or compliance.
• Demonstrated knowledge of TJC and NCQA PCMH accreditation standards and processes.
• Experience leading organizational readiness for accreditation surveys.
• Basic Life Support through AHA required

Work Environment

• Standard office environment with occasional travel to healthcare facilities within the
• system.
• Remote work available when appropriate, in consultation with supervisor.
• Must be available during accreditation surveys and periodic after-hours work as needed.