Director, Accreditation Services

Position Summary Provides direction, leadership and coordination of all Continuous Survey Readiness preparation and on-sites activities for The Joint Commission, as well as other accreditation or regulatory responsibilities as required. Coordinates and communicates the process of continued readiness for announced and unannounced surveys, standards compliance, with primary responsibility for Joint Commission standards, CMS Standards of Participation, related patient and co-worker safety initiatives, and coordinates Joint Commission Point-of-Care Lab Surveys. Creates and main data bases to support and drive accreditation functions using Tracers with AMP. Participates in quality and process improvement initiatives. Actively engaged with changes and updates to accreditation and regulatory standards. Provides education and informational updates to accredited and non-accredited system entities. Serves as Peer Review Contact for Georgia Hospital Association, Public Health and Accountability and Georgia Medical Care Foundation. Education Bachelor's Degree in Nursing, Healthcare Administration or related field

• Required Master's Degree
• Preferred Experience 5-7 Years Accreditation, Performance Improvement, Quality experience
• Required License & Certification Professional License with State of Practice
• Required Core Job Functions Documents and reports are processed to facilitate regulatory and System compliance, as applicable.

Electronic and paper documents are maintained. Educates and updates are made to departments, units, and committees to maintain continued survey readiness. Official accreditation correspondence is communicated to Leadership in a timely manner. Submits required reports and responses based on result of accreditation surveys. Develops compliance strategies by working with system departments and units.