Associate Director, Accreditation

Scope of Position

The Associate Director of Accreditation and Licensing will lead a team of highly skilled and motivated health care professionals. The Associate Director of Accreditation & Licensure will be a certified quality professional and have a strong understanding of Lean practices as well as an expert in rules & regulations. The Associate Director will serve as an expert resource and provide insight to assure compliance with regulatory bodies including JCAHO, state (ODH), and federal guidelines.

This position directs the hospital's operations & activities to comply with all accreditations, regulation, & licensing requirements for all health care sites & services across the continuum. Translates various accrediting, regulatory & licensing agency requirements into action plans to achieve positive survey/audit reviews and implements systems to effectively monitor compliance to standards & to implement new processes to meet new requirements. The Associate Director serves as a professional resource throughout the health system to interpret Joint Commission standards, Ohio Department of Health, Center for Medicare regulations and other accrediting agencies applicable to the hospital and ambulatory environment. In addition to these regulatory bodies, the leader will be involved in the Commission on Cancer, and the accrediting bodies such as the National Accreditation Program for Breast Centers (NAPBC) and other voluntary disease accreditation programs supported by The James.

The scope of regulatory oversight includes all current and planned inpatient hospital beds (~500+ future), and all ambulatory sites including The James outpatient care, Stephanie Speilman Comprehensive Breast Center, Martha Morehouse Tower, New Albany, Dublin, Powell, all mammography regional sites, and all future provider-based locations.

Position Summary

The Associate Director of Accreditation and Licensing is responsible for management of departmental operations, evaluation of manager and employee performance, demonstrating customer satisfaction and strategic and operational planning and program development. The Associate Director serves as a leader and mentor both within the department and throughout the medical center. The Associate Director demonstrates knowledge of governmental & other regulatory standards, requirements, & guidelines related to quality improvement, such as The Joint Commission, NCQA, Federal HMO Act, CMS Conditions of Participation, OSHA, FDA, HIPAA & Medical & Medicare regulations & standards. Has a strong working knowledge of ongoing monitoring techniques (including criteria development & statistical analysis); medical care delivery in hospital & outpatient settings; total quality management principles, tools, & techniques. Must have effective communication, negotiation and leadership skills.

Minimum Qualifications

For Hire:

Master's Degree in Nursing or a Healthcare related field or equivalent combination of education and experience. 7 years of relevant experience required. 12 or more years of relevant experience preferred.

Required Qualifications
Master’s degree in health-related field or equivalent combination of education and experience. Clinical background highly desirable.

FUNCTION: Health Care Administration

SUB-FUNCTION: Accreditation

CAREER BAND: Managerial

CAREER LEVEL: M3