Program Manager Accreditation

Cleveland Clinic•Great Barrington, MA

1d•Onsite

About The Position

The Program Manager, Accreditation coordinates hospital accreditation activities and ensures continuous survey readiness across Fairview Hospital, affiliated organizations, and off-site facilities. The role collaborates with senior leadership to identify and implement interventions that promote continuous survey readiness and support compliance with accreditation standards. It also provides support to other hospitals, particularly those within the West Submarket. The position develops and manages programs to 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). It serves as a resource for staff and advises departments and institutes on regulatory requirements, certifications, standards, and interpretations. The Program Manager supports on-site and unannounced surveys, develops projects related to accreditation and compliance, and works with Quality and Patient Safety teams to support safe, high-quality care and continuous improvement. The role reviews accreditation findings, prepares plans of correction for accrediting organizations, and monitors corrective actions. It interprets accreditation standards and standard operating procedures to identify solutions, maintains proficiency across applicable accreditation programs, provides cross-coverage for other facilities as needed, and travels to local Fairview affiliate locations as required. The schedule is days, 7:30 a.m. to 4:30 p.m.

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; OR an associate's degree and seven years of experience; OR a master's degree and four years of experience.
Ability to operate office equipment with manual dexterity.
Ability to lift and transport up to 15 pounds.
Ability to stand, walk, and sit for extended periods.
Normal or corrected vision and hearing.
Follow Standard Precautions and use personal protective equipment as required for procedures.

Nice To Haves

Master’s degree.
Healthcare background.
RN or clinical experience.
Joint Commission experience.
Accreditation experience.

Responsibilities

Develop, manage, and maintain programs to ensure compliance with accreditation and regulatory standards, including TJC, ODH, and CMS requirements.
Serve as a primary resource for staff, facilitating program operations and providing guidance on accreditation requirements.
Consult with departments and institutes on TJC and other regulatory agency requirements.
Educate clinical and nonclinical departments and distribute accurate information about certifications, accreditation standards, and regulatory interpretations.
Participate in preparation for and support of on-site survey activities, including responding to unannounced surveys.
Collaborate with departments across the Quality and Patient Safety Institute to promote safe, high-quality patient care and continuous survey readiness.
Develop, manage, and coordinate projects related to accreditation and regulatory compliance.
Participate in committees and meetings supporting accreditation initiatives and continuous improvement.
Review accreditation findings and improvement opportunities, develop plans of correction for accrediting organizations, and monitor corrective actions for sustained compliance.
Interpret and apply accreditation standards and standard operating procedures to identify solutions for institutes and departments.
Develop proficiency in applicable accreditation standards and support a variety of accreditation programs and regulatory requirements.
Provide cross-coverage for other facilities as needed.
Travel to local Fairview affiliate locations as required.
Perform other duties as assigned.