Employment Type:

Shift:

Description:

Purpose: responsible for managing internal audits, preparing accreditation documentation, coordinating site evaluations, and ensuring that policies are continually updated to meet legal and governance frameworks

What you will do:

Accreditation & Regulatory Compliance

• Oversee all accreditation processes, including preparation, submission, and maintenance of certifications
• Interpret and implement regulatory requirements from accrediting agencies
• Serve as the primary liaison with accreditation bodies and regulatory agencies
• Monitor changes in laws, regulations, and standards; communicate updates to leadership

Audit & Readiness Management

• Plan, conduct, and coordinate internal audits and mock surveys
• Lead readiness initiatives for external accreditation surveys and inspections
• Identify compliance gaps and develop corrective action plans (CAPAs)
• Track remediation activities to closure and ensure ongoing compliance

Policy & Procedure Governance

• Develop, review, and update organizational policies and procedures
• Ensure alignment with industry standards and accreditation requirements
• Maintain centralized documentation and compliance records

Training & Education

• Design and deliver compliance training programs for staff and leadership
• Educate teams on accreditation standards and regulatory obligations
• Promote a culture of accountability and continuous improvement

Data Analysis & Reporting

• Monitor key compliance metrics and performance indicators
• Prepare reports and dashboards for executive leadership
• Analyze trends to identify risk areas and improvement opportunities

Cross-Functional Collaboration

• Partner with clinical, operational, HR, and quality teams
• Support department leaders in implementing compliance initiatives
• Participate in quality improvement and risk management programs

Minimum Qualifications:

Education

• Bachelor’s degree in Healthcare Administration, Business, Public Health, or related field
• Master’s degree (preferred)

Experience

• 5–8+ years of experience in compliance, accreditation, quality, or regulatory roles
• Experience with accrediting bodies (e.g., Joint Commission, NCQA, CMS, CARF, ISO)
• Proven experience leading audits or accreditation surveys

Certifications (Preferred)

• Certified Professional in Healthcare Quality (CPHQ)
• Certified Compliance & Ethics Professional (CCEP)
• Lean/Six Sigma certification (a plus)

Skills & Competencies

• Strong knowledge of regulatory and accreditation standards
• Excellent analytical and problem-solving abilities
• High attention to detail and organizational skills
• Strong leadership and project management capabilities
• Effective communication and stakeholder management skills
• Ability to manage multiple priorities and deadlines

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.