Director-Accreditation

Mayo Clinic•Rochester, MN

About The Position

Mayo Clinic seeks an accomplished, visionary leader to serve as the Director of Accreditation, the enterprise executive responsible for system‑wide oversight of accreditation across hospitals, critical access hospitals, ambulatory and home care settings, behavioral health, disease‑specific certifications, and other programs as assigned. The Director will ensure sustained readiness and exemplary performance against federal and accrediting body requirements, including CMS, HHS, State Departments of Health, The Joint Commission (TJC), and DNV Healthcare—translating complex regulations into clear, reliable practices that create safer systems for patients and elevate care. Primary Accountabilities Enterprise Strategy & Governance: Set the vision and strategic direction for Mayo Clinic’s Accreditation Program; lead planning, implementation, and evaluation of accreditation and regulatory activities across all sites to maintain accreditation status and CMS certification. Continuous Readiness & Risk Mitigation: Advance proactive tracer methods and readiness practices that integrate survey, tracer, and operational data to identify risk early, reduce harm, and accelerate improvement. Survey Excellence: Direct end‑to-end survey management, including onsite regulatory surveys and investigations by accrediting, state, and federal agencies; oversee corrective actions and ensure sustained outcomes post‑survey. Modernization & Automation: Champion modernization of accreditation tools and processes—leveraging data, automation, and AI‑enabled regulatory monitoring—to reduce burden, increase reliability, and measurably enhance patient safety. Education & Communication: Lead enterprise interpretation of standards and communicate requirements in accessible, actionable ways; equip leaders and frontline teams with resources that embed accreditation into daily clinical practice. External Representation: Serve as Mayo Clinic’s liaison to accrediting, licensing, and regulatory bodies; provide leadership and advocacy through participation in accrediting body committees and national policy forums. People & Financial Stewardship: Manage accreditation staff across the enterprise and provide financial oversight for the accreditation budget, fostering a high‑performing, mission‑driven team. The successful candidate views accreditation as a catalyst for transformation and measurable improvement in patient outcomes. This leader harmonizes scientific rigor with practical execution—making standards intuitive, embedding reliability into daily workflow, and ensuring that continuous readiness translates into safer care for patients and teams alike. The Value of this Role Mayo Clinic’s Accreditation Program is recognized as best‑in‑class, with standardized proactive readiness strategies, tools, and resources that enable clinicians to focus on delivering safe, exceptional care while maintaining an unwavering compliant posture. The Director will elevate this foundation—linking standards to safety, modernization, and enterprise value.

Requirements

Master's degree in business, health care administration, or related field
10 years of progressive healthcare management or regulatory compliance experience
Demonstrated excellence in written and verbal communication
Proven change leadership, strategic planning, and operational execution
High integrity, executive presence, and creativity
Expertise in conflict management
Expertise in systems thinking
Expertise in team dynamics
Expertise in outcomes management
Expertise in continuous improvement methodologies
Expertise in risk assessment/management
Significant experience with Joint Commission standards, CMS Conditions of Participation, and external regulatory requirements
Ability to translate complex regulations into meaningful expectations that are readily communicated across the organization at all levels
Supports flexible solutions to ensure regulatory compliance and balance practice innovation
Manages resources effectively and plans for resources needed to support prioritized programs

Nice To Haves

Clinical degree (e.g., RN, PT, RT) or advanced certifications in compliance/accreditation preferred
CPHQ, CPHRM, or HACP are valued
Juris Doctor degree or advanced certifications in compliance or accreditation preferred

Responsibilities

Set the vision and strategic direction for Mayo Clinic’s Accreditation Program
Lead planning, implementation, and evaluation of accreditation and regulatory activities across all sites to maintain accreditation status and CMS certification
Advance proactive tracer methods and readiness practices that integrate survey, tracer, and operational data to identify risk early, reduce harm, and accelerate improvement
Direct end‑to-end survey management, including onsite regulatory surveys and investigations by accrediting, state, and federal agencies
Oversee corrective actions and ensure sustained outcomes post‑survey
Champion modernization of accreditation tools and processes—leveraging data, automation, and AI‑enabled regulatory monitoring—to reduce burden, increase reliability, and measurably enhance patient safety
Lead enterprise interpretation of standards and communicate requirements in accessible, actionable ways
Equip leaders and frontline teams with resources that embed accreditation into daily clinical practice
Serve as Mayo Clinic’s liaison to accrediting, licensing, and regulatory bodies
Provide leadership and advocacy through participation in accrediting body committees and national policy forums
Manage accreditation staff across the enterprise and provide financial oversight for the accreditation budget, fostering a high‑performing, mission‑driven team