Director of Accreditation

Job Summary:

The Director of Accreditation leads and manages the regulatory readiness and accreditation programs across Grady Health System to ensure compliance with all applicable standards from The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and other federal, state, and local regulatory agencies. The Director works collaboratively across departments to embed a culture of continuous readiness and supports the achievement of safe, high-quality patient care system wide.

Job Description:

Accreditation & Regulatory Compliance
- Oversee and manage all aspects of the hospital's accreditation activities, including TJC surveys (hospital, laboratory, behavioral health, etc.), CMS Conditions of Participation, and state licensing requirements.
- Develop and maintain a comprehensive continuous readiness program across inpatient, outpatient, and ancillary services.
- Monitor regulatory changes and proactively adjust policies and practices to maintain compliance.

Survey Preparedness
- Lead and coordinate mock surveys, readiness rounds, tracer methodologies, and documentation audits.
- Serve as the primary liaison with TJC, CMS, Georgia Department of Community Health, and other external regulatory agencies.
- Guide staff and leadership in real-time during surveys, including leading command centers and surveyor escorts.

Performance Improvement & Policy Integration
- Collaborate with department leaders and quality teams to drive corrective actions and ensure timely resolution of identified deficiencies or citations.
- Maintain and support the system-wide policy and procedure framework to ensure alignment with current standards and practices.

Education & Training_20%
- Develop and lead education and training programs on accreditation standards, compliance expectations, and survey preparedness.
- Build regulatory literacy across the organization to empower leaders and frontline staff.

Documentation & Reporting_10%
- Maintain all required documentation for regulatory bodies, including Plans of Correction, Statements of Deficiency, and periodic self-assessments.
- Track and report on accreditation metrics and readiness indicators to executive leadership.

Job Qualifications:

• Bachelor's degree in Nursing, Healthcare Administration, or a related field
• Master's degree in Nursing, Public Health, Health Administration, or related field
• Eight (8) or more years of job-related experience
• Minimum 5-7 years of experience in regulatory/accreditation leadership in a hospital or health system
• In-depth knowledge of TJC, CMS, and state regulatory standards.
• Experience leading TJC survey preparation and execution.
• Experience in a large, complex, urban academic medical center or public hospital

• Certification in Healthcare Accreditation (e.g., HACP, CPPS.

• Expertise in accreditation standards, regulatory compliance, and healthcare operations.
• Exceptional communication, collaboration, and coaching skills.
• Strong project management and problem-solving capabilities.
• Ability to lead under pressure and adapt to rapidly changing regulatory environments.