Associate Director, Accreditation and Compliance

The Ohio State University

1d • Onsite

About The Position

The position provides strategic leadership and oversight for all accreditation, regulatory compliance, and life safety activities across The James Cancer Hospital and Solove Research Institute. It is responsible for conducting assessments, coordinating education, managing surveys and responses, and implementing systems to monitor compliance with evolving standards. The role prepares and submits required documentation to local and national regulatory bodies, evaluates the effectiveness of corrective actions, and supports continuous quality improvement to ensure safe, high‑quality, and compliant healthcare delivery. It ensures organizational policies align with legal and regulatory requirements and provides education on policy updates. Serving as a subject matter expert for the Comprehensive Cancer Center program, the leader interprets standards and regulations from bodies such as the Joint Commission, Ohio Department of Health (ODH), Centers of Medicare and Medicaid Services (CMS), and Columbus Public Health, while also supporting additional accreditations including the Commission on Cancer. The position oversees hospital licensing, coordinates ODH-related activities, and leads Emergency Preparedness efforts for the organization.

The Associate Director of Accreditation and Compliance is responsible for management of departmental operations, evaluation of employee performance, ensures the department demonstrates customer satisfaction and strategic, operational planning and program development. Has a strong working knowledge of ongoing monitoring techniques (including total quality management principles, tools, & techniques); clinical operations in hospital & outpatient settings. The Associate Director is responsible for ensuring that the facility remains in compliance with Joint Commission, State and Federal standards with oversight and responsibility for all regulatory body surveys, i.e., Joint Commission, State Licensing and Reviews, CMS Validation Surveys, Health Department, local regulatory reviews (fire marshal), and any other regulatory activity that involves the facility. This responsibility includes staying current with Joint Commission, state, and local standards, educating facility staff about standards, and preparing the facility for surveys. Plans and coordinates accreditation and regulatory compliance activities to assure safe, high quality and regulatory compliant healthcare delivery. This includes involvement in the development and implementation of hospital-wide performance improvement plans and valuation of effectiveness of corrective actions for identified problems and continuous quality improvement activities. Responsible for the overall leadership of implementation of the organization’s Accreditation and Regulatory Plan; evaluation of the quality of care provided to people receiving support from all organizational entities; and the organization-wide monitoring, analysis, and improvement of program processes. Also responsible for coordinating and directing varied functions in the programs across the organization to provide an integrated approach to quality improvement and management related to regulatory activity. Responsible for ensuring policies are compliant with legal standards, the rules and regulations of regulatory agencies, and that education is provided to the organization on policies and procedures updates. This position coordinates and collaborates with the Enterprise Emergency Preparedness and Life Safety Program at The James.

Requirements

• Master's Degree in Nursing or a Healthcare related field or equivalent combination of education and experience.
• 6 years’ experience in accreditation survey preparation and coordination.
• Databases, spreadsheets, and graphics required.
• Must meet mandatory educational and health requirements.

Nice To Haves

• 5 years patient care experience
• 3 Years in leadership Hospital or Outpatient management experience, including but not limited to regulatory & licensing, accreditation, performance improvement, risk management and quality assurance in an acute care hospital.
• Current experience (within the last three years) with regulatory survey process and development of regulatory plans of correction/action plans.
• Knowledge of medical staff oversight/credentialing
• Current licensure if applicable
• Maintains and seeks new knowledge related to regulatory oversight, emergency preparation, current policies, procedures, and protocols.

Responsibilities

• Provides strategic leadership and oversight for all accreditation, regulatory compliance, and life safety activities.
• Conducts assessments, coordinates education, manages surveys and responses, and implements systems to monitor compliance.
• Prepares and submits required documentation to local and national regulatory bodies.
• Evaluates the effectiveness of corrective actions and supports continuous quality improvement.
• Ensures organizational policies align with legal and regulatory requirements and provides education on policy updates.
• Interprets standards and regulations from bodies such as the Joint Commission, Ohio Department of Health (ODH), Centers of Medicare and Medicaid Services (CMS), and Columbus Public Health.
• Supports additional accreditations including the Commission on Cancer.
• Oversees hospital licensing and coordinates ODH-related activities.
• Leads Emergency Preparedness efforts for the organization.
• Manages departmental operations and evaluates employee performance.
• Ensures the department demonstrates customer satisfaction and strategic, operational planning and program development.
• Ensures the facility remains in compliance with Joint Commission, State and Federal standards.
• Oversees all regulatory body surveys (Joint Commission, State Licensing and Reviews, CMS Validation Surveys, Health Department, local regulatory reviews).
• Stays current with Joint Commission, state, and local standards, educates facility staff, and prepares the facility for surveys.
• Plans and coordinates accreditation and regulatory compliance activities.
• Involves in the development and implementation of hospital-wide performance improvement plans.
• Evaluates the effectiveness of corrective actions for identified problems and continuous quality improvement activities.
• Leads the implementation of the organization’s Accreditation and Regulatory Plan.
• Evaluates the quality of care provided to people receiving support from all organizational entities.
• Monitors, analyzes, and improves program processes organization-wide.
• Coordinates and directs varied functions in the programs across the organization to provide an integrated approach to quality improvement and management related to regulatory activity.
• Ensures policies are compliant with legal standards and the rules and regulations of regulatory agencies.
• Provides education to the organization on policies and procedures updates.
• Coordinates and collaborates with the Enterprise Emergency Preparedness and Life Safety Program.

Benefits

• Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost.
• Paid time off, including sick and vacation time and 11 holidays.
• State retirement plan or an alternative retirement plan, both with generous employer contributions.

What This Job Offers

• Job Type: Full-time
• Career Level: Director