Senior Director of Accreditation

Cleveland Clinic

6d•Onsite

About The Position

The Senior Director of Accreditation leads the strategy, implementation, and oversight of accreditation and regulatory readiness across Cleveland Clinic’s enterprise hospitals in Ohio and Florida. In collaboration with the Senior Director of Regulatory Affairs, this role oversees accreditation activities before, during, and after surveys conducted by agencies including The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), and the Ohio Department of Health (ODH). The Senior Director serves as an enterprise resource and consultant, leads on-site survey activities, and partners with clinical, operational, and executive leaders to advance regulatory readiness, safety, quality, and continuous improvement. The role also supports acquisition due diligence and onboarding and provides regulatory and accreditation guidance for international initiatives. The position leads a team of approximately 33 caregivers and is responsible for strengthening the enterprise approach to accreditation and readiness, developing a cohesive, high-performing team, and embedding continuous improvement into everyday operations. The caregiver works Monday through Friday, 8:00 a.m. to 5:00 p.m., with on-call responsibilities and 5%–10% travel. The role is based at Cleveland Clinic Main Campus in Cleveland.

Requirements

Bachelor’s degree in a health-related field.
Healthcare Accreditation Certified Professional (HACP) or Certified Joint Commission Professional (CJCP) certification; applicants without one of these certifications must achieve certification within one year.
Ten years of healthcare experience in a clinical discipline, including at least five years of accreditation experience and five years of leadership or management experience.
Specific experience related to accreditation and regulatory bodies, such as CMS and state licensing agencies.
In-depth knowledge of accrediting and regulatory standards.
Demonstrated ability to interpret standards, serve as a subject matter expert, and communicate information to all levels of the organization.
Ability to manage employees and prioritize and manage multiple tasks simultaneously.
Demonstrated leadership skills.
Excellent communication skills.

Nice To Haves

Master’s degree.
Experience in international accreditation.
Demonstrated experience leading accreditation, regulatory, quality, or patient safety programs within a complex healthcare organization.
Experience leading and developing multidisciplinary teams, preferably across multiple hospitals or markets.
Demonstrated success leading organizational change, standardizing processes, and improving operational performance.
Strong executive presence and ability to influence and collaborate with senior clinical and operational leaders.
Experience applying continuous improvement methodologies to achieve sustainable results.
Ability to balance strategic leadership with operational execution.

Responsibilities

Direct TJC activities, including application submission, survey planning and logistics, post-survey Evidence of Standards Compliance (ESC), and annual intracycle monitoring.
Direct continuous readiness activities, including Continuous Readiness Rounds, Tracer Teams, Mock Surveys, intranet accreditation site content, and educational materials and activities.
Lead and coordinate regulatory on-site surveys, including surveys conducted by TJC, ODH, and CMS.
Develop effective post-survey action plans and formal responses to accrediting and regulatory agencies.
Maintain current knowledge of accreditation and compliance issues affecting healthcare.
Stay informed about changes in TJC and Joint Commission International standards, Ohio Administrative Code and Ohio Regulatory Code, and CMS Conditions for Coverage and Conditions of Participation requirements and standards.
Communicate changes to standards to executive leadership and others in the organization who need to know.
Collaborate with Enterprise Quality Departments and organization Institutes to ensure compliance with accreditation standards and regulatory requirements.
Support acquisition due diligence and onboarding activities and provide regulatory and accreditation guidance for international initiatives.
Lead and develop a team of approximately 33 caregivers.
Perform other duties as assigned.