Accreditation and Governance Specialist

Centerstone•Bradenton, TN

1d•$50,700 - $71,100

About The Position

The Accreditation and Governance Specialist supports Centerstone’s enterprise Accreditation & Quality Governance program by promoting continuous survey readiness, regulatory compliance, and consistent implementation of accreditation standards across all markets and service lines. The role partners with operational leaders to interpret standards, conduct mock surveys and tracers, monitor corrective action plans, and prepare for regulatory and accreditation surveys. The specialist serves as a subject matter resource on accreditation requirements and collaborates with Clinical Excellence, Clinical Risk Management, Patient Voice & Experience, Policy Governance, and operational teams to strengthen organizational quality and regulatory compliance. The position also supports SAMHSA survey activities; certification of Centerstone locations in the National Health Service Corps (NHSC) and staff enrollment opportunities; and compliance with federal Affordable Care Act Rule 1557 nondiscrimination activities. Work may take place in office, clinical, residential, or community-based environments, depending on the role and assignment. The position is classified as sedentary and may involve prolonged sitting, standing, walking, and computer use. Periodic travel may be required. Work hours may include evenings, weekends, holidays, or extended shifts based on program needs. The role has no supervisory responsibilities.

Requirements

Bachelor’s degree in Social Work, Health and Human Services, Healthcare Administration, Nursing, Public Health, or a related field.
Three years of experience in healthcare quality, accreditation, compliance, clinical operations, or a related healthcare field.
Working knowledge of healthcare accreditation standards and survey processes.
Knowledge of continuous survey readiness principles.
Ability to interpret regulatory and accreditation requirements.
Strong organizational and project management skills.
Excellent written and verbal communication skills.
Strong facilitation and relationship-building abilities.
Strong attention to detail.
Ability to prioritize multiple projects and deadlines.
Ability to analyze compliance gaps and recommend practical solutions.
Proficiency with Microsoft Office applications and electronic documentation systems.

Nice To Haves

Knowledge of behavioral healthcare operations.
Experience participating in accreditation surveys, mock surveys, regulatory reviews, or quality improvement activities.
Certified Professional in Healthcare Quality (CPHQ).
Licensed healthcare professional, when applicable.
Experience in behavioral healthcare.
Experience within a large multi-site or multistate healthcare organization.
Experience supporting Joint Commission, CARF, CMS, or state licensing surveys.
Experience conducting mock surveys or tracer activities.
Experience interpreting accreditation standards and regulatory requirements.
Experience collaborating with interdisciplinary operational teams.
Experience developing or monitoring corrective action plans.

Responsibilities

Support enterprise accreditation readiness initiatives across Centerstone markets and service lines.
Conduct mock surveys, tracers, and readiness assessments to evaluate compliance with accreditation standards and organizational policies.
Partner with operational leaders to identify improvement opportunities and strengthen continuous survey readiness.
Assist with accreditation and regulatory survey preparation, including document review, evidence collection, and survey logistics.
Monitor compliance with accreditation standards and communicate risks or deficiencies to leadership.
Assist in developing and monitoring corrective action plans following surveys, tracers, and regulatory reviews.
Collaborate with operational leaders to ensure timely corrective actions and ongoing compliance activities.
Provide education and consultation on accreditation standards, regulatory expectations, and survey readiness.
Interpret accreditation standards and communicate updates to operational leaders.
Participate in enterprise readiness committees and quality governance activities.
Collaborate with Policy Governance to align policies and procedures with accreditation standards and regulatory requirements.
Collaborate with Clinical Excellence to incorporate chart review, tracer, and clinical quality evaluation findings into survey readiness efforts.
Collaborate with Operations and Clinical management to identify trends affecting accreditation readiness or regulatory compliance.
Complete activities associated with SAMHSA surveys.
Complete activities necessary to certify Centerstone locations in the National Health Service Corps (NHSC) and support staff enrollment opportunities in NHSC programs.
Assist with activities to ensure compliance with Federal Rule 1557 of the Affordable Care Act concerning nondiscrimination.
Maintain documentation and records related to accreditation readiness activities.
Participate in enterprise quality improvement initiatives as assigned.
Represent the department on internal organizational committees and functions, and represent Centerstone externally with relevant stakeholders.
Travel periodically as needed to support organizational priorities, including leadership collaboration, incident response, staff development, and other Clinical Risk Management initiatives.
Perform other duties as assigned.