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Manager, Hospital Accreditation Services - Compliance - FT

Posted on Aug 16, 2019 by Southeast Georgia Health System

Meridian, GA 31319
Health Care
Immediate Start
Annual Salary
Southeast Georgia Health System has an exciting opportunity for a Manager of Accreditation Services in our Compliance Department. If you are a Registered Nurse (RN) with experience in hospital accreditation, healthcare accreditation, hospital quality, or healthcare quality, this could be your opportunity to continue your career with a growing health system in the beautiful Golden Isles of Georgia!

Summary: Responsible for management of the Accreditation/Certification processes for the Health System. Facilitates the compliance with The Joint Commission ("TJC") Standards for Hospital Accreditation, with the goal of obtaining full accreditation for both the Brunswick and Camden Campuses. Additionally, assists and facilitates other accreditation/certifications being sought by the Health System.

The Manager, Accreditation Services has the following essential responsibilities:
  • Program Development: Manages and directs implementation of TJC's Hospital Accreditation Standards Manual program, and chairs the monthly Continuous Survey Readiness ("CSR") Committee meetings for the two (2) hospitals on the Brunswick and Camden Campuses. Directs the planning, development, implementation, and refinement of the Health System's CSR program, with the goal of maintaining full TJC Accreditation for both hospitals.
  • Internal Communication Activities: Manages Health System compliance with TJC and other accrediting organizations, including CMS and the Georgia Department of Community Health.
  • External Liaison with National / State Accreditation Organizations: Cultivates and manages Health System relationships with accreditation organizations.
  • Health System Policies & Procedures Management: Has direct oversight of the Health System's electronic policy system, Policy Tech, to ensure compliance with TJC, Medicare Conditions of Participation, and other Federal, State, and local regulations.
  • Education & Training: Facilitates and coaches Leadership, team members, and physicians in best practices and process improvements, and provides ongoing education on new regulations to achieve organizational goals.

The ideal Manager, Accreditation Services candidate will possess the following minimum qualifications:
  • Minimum Diploma or an Associate's Degree from an accredited school of nursing required. Bachelor's degree in a healthcare related field, or Graduate of a Bachelor's or Master's School of Nursing, preferred.
  • Minimum five (5) years' experience in managing hospital accreditation programs and/or experience in working in a hospital quality department with responsibility for managing accreditation.
  • Nursing license required in State of Georgia.
  • Upon completion of two (2) years of experience in the position, individual will be expected to obtain certification from The Joint Commission as a Joint Commission Certified Accreditation Professional
  • Must possess strong leadership skills (i.e., task completion, motivation) and be able to plan, develop, implement, and evaluate programs.
  • Possess strong analytical skills.
  • Ability to communicate clearly, verbally and in writing.
  • Interpersonal skills required to interact and partner at various levels, both internal and external, on behalf of the Health System.
  • Organized and detail-oriented; capable of handling multiple priorities, and working independently.
  • Express a supportive, customer service-oriented attitude with a demonstrated ability to attain results.
  • Display proficiency in computer skills

Service Excellence: All team members of Southeast Georgia Health System will promote service excellence by developing and maintaining positive relationships with customers, other team members, and the medical staff and will ensure the highest quality of care by performing their responsibilities according to the highest professional standards.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, or national origin. EOE/AA: M/F/D/V


Reference: 746019993

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