Program Manager Accreditation

Cleveland Clinic

1d•Onsite

About The Position

The Program Manager, Accreditation coordinates hospital accreditation activities and ensures continuous survey readiness across Cleveland Clinic, affiliated organizations, and off-site facilities. The role collaborates with senior leadership and departments to develop and implement interventions that support ongoing readiness and compliance with accreditation and regulatory requirements. The manager serves as a resource and consultant for staff and departments on accreditation standards, certifications, and regulatory requirements. The position supports onsite survey preparation and activities, works directly with surveyors during reviews—including unannounced surveys—and oversees follow-up on findings, plans of correction, and sustained compliance. It also leads accreditation-related projects, conducts organizational rounds to identify vulnerabilities and improvement opportunities, and participates in relevant committees and meetings. The schedule is Monday through Friday, 7:00 a.m. to 4:00 p.m. The role is based at Cleveland Clinic Main Campus in Cleveland.

Requirements

Bachelor’s degree in Nursing, Healthcare Administration, Business, Engineering, or a related field and five years of related experience in Quality Management, Risk Management/Patient Safety, Performance Improvement programs, or related healthcare experience; alternatively, an associate’s degree and seven years of experience, or a master’s degree and four years of experience.
Demonstrated knowledge of risk management principles and quality and performance improvement methods.
Working knowledge of accreditation and regulatory standards.
Healthcare Accreditation Certification Program (HACP) or Certified Joint Commission Professional (CJCP) certification required within two years of hire.

Nice To Haves

Master’s degree.
Healthcare background.

Responsibilities

Develop, manage, and maintain programs that ensure compliance with accreditation and regulatory standards, including requirements from The Joint Commission (TJC), the Ohio Department of Health (ODH), and the Centers for Medicare & Medicaid Services (CMS).
Serve as a primary resource for staff and facilitate effective operation of accreditation and regulatory programs.
Provide consultation to departments and institutes on TJC and other regulatory agency requirements.
Educate clinical and nonclinical departments and disseminate accurate information about certifications, accreditation requirements, and interpretations of regulatory standards.
Participate in preparation for and support onsite accreditation and regulatory survey activities.
Collaborate with departments throughout the Quality and Patient Safety Institute to promote safe, high-quality patient care.
Develop, manage, and oversee projects related to accreditation and regulatory compliance.
Conduct rounds throughout the organization to identify vulnerabilities, assess compliance, and engage staff in improvement opportunities.
Work with departments and institutes to implement practices aligned with CMS, TJC, and other regulatory requirements.
Work directly with accreditation and regulatory agency surveyors during onsite reviews, including unannounced surveys.
Review survey findings and accreditation correspondence; develop plans of correction, submit them for organizational approval, and monitor implementation for sustained compliance.
Develop proficiency in applicable accreditation standards, regulatory requirements, and standard operating procedures through education, self-study, and experience.
Support accreditation programs and requirements across the organization, adapting to the needs of different departments and institutes.
Participate in committees and meetings related to accreditation, regulatory compliance, and patient safety.
Perform other duties as assigned.