Accreditation Manager, Quality Outcomes - Full Time - Days - Corporate
About The Position
The Accreditation Manager, Quality Outcomes coordinates ongoing activities to support the organization’s continual readiness for accreditation, CMS surveys, and state licensure surveys. The manager serves as the point of contact for accreditation-related issues and guides and assists departments in meeting regulatory requirements. This role establishes and implements systems and processes for continuous adherence to regulatory standards within the assigned medical center, and leads and coordinates Joint Commission Medical Center Accreditation surveys. It also supports quality improvement teams, works with legal and risk management on adverse-event tracking and root cause analysis, and helps ensure timely risk-mitigation strategies. The position participates in developing and implementing policies, programs, and initiatives to improve the overall quality of patient care services, and performs other related duties as assigned.
Requirements
- Bachelor's degree in Nursing, Healthcare, or a related field.
- 3–5 years of experience in quality improvement, patient safety, accreditation, or a relevant area.
- Current New Jersey Registered Nurse licensure or clinical licensure.
Nice To Haves
- Master's degree in Healthcare, Business Administration, or a related field.
- Five years of clinical experience within an acute care hospital or health system.
- Knowledge of The Joint Commission (TJC) accreditation and CMS regulatory requirements.
- Certified Professional in Healthcare Quality or Accreditation.
Responsibilities
- Establish and implement systems and processes to ensure continuous adherence to regulatory standards within the assigned medical center.
- Lead and coordinate Joint Commission Medical Center Accreditation surveys.
- Identify improvement opportunities and provide support or consultative services to quality improvement teams.
- Collaborate with legal and risk management teams to track and trend adverse events, conduct root cause analysis reviews, and ensure development and timely execution of risk-mitigation strategies.
- Participate in developing and implementing policies, programs, and initiatives to improve the overall quality of patient care services.
- Perform other related duties as assigned.
Benefits
- Medical, dental, vision, and prescription coverage for eligible team members working 22.5 hours per week or above.
- Life and AD&D insurance.
- Short-term and long-term disability coverage, with options to supplement.
- 403(b) retirement plan with employer match and additional non-elective contribution.
- PTO and paid sick leave.
- Tuition assistance, advancement opportunities, and academic advising.
- Parental, adoption, and surrogacy leave.
- Backup and on-site childcare.
- Well-being rewards.
- Employee Assistance Program (EAP).
- Fertility benefits and Healthy Pregnancy Program.
- Flexible Spending and commuter accounts.
- Pet, home and auto, identity theft, and legal insurance.
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What This Job Offers
Job Type
Full-time
Career Level
Manager
