Accreditation Manager
Southeastern, LA area

Currently seeking a talented and dedicated Accreditation Manager for a great opportunity in the Southeastern, LA area. The ideal candidate will possess 5+ years of current experience working in an acute care hospital and have 3+ years of experience working in an Accreditation Department in a leadership role.

Responsibilities of the Accreditation Manager

  • Monitor hospital-wide compliance with regulatory and accrediting agencies (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing) to ensure ongoing survey readiness.
  • Facilitate and coordinate hospital-wide data collection, measurement, trending and dissemination of information regarding regulatory standards and compliance (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).
  • Inform all management levels regarding current developments and changes in regulatory standards (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).
  • Provides regulatory education to new and existing hospital staff and medical staff to achieve and maintain compliance.
  • Assists in facilitating quality improvement teams assuring the implementation of strong quality improvement strategies using proven quality methods, tools/techniques.
  • Initiate, coordinate and support necessary changes or action plans and hospital-wide and department-specific performance improvement projects to support regulatory agency standards.
  • Oversees and directly supervises the activities and functioning of the PI Coordinator and Peer Review including interviewing, coaching, counseling, orientation, training and evaluation within established guidelines.
  • Monitors the day-to-day operations of assigned department staff, reacting effectively and efficiently to unplanned circumstances, demands and challenges facing the department to ensure consistent quality of service.
  • Coordinates other regulatory standards (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).initiatives activities as appropriate.

Requirements of the Accreditation Manager

  • Bachelor's degree in nursing or health-related science field
  • Master’s degree in health-related field preferred
  • MUST BE A RN ( will only consider a Non RN if they extremely strong with Accreditation Experience
  • Louisiana State RN license or compact license is accepted
  • 2-3 years healthcare experience in Accreditation, performance improvement abd JCHAO
  • Healthcare experience should be recent and within a clinical setting
  • Proficiency with performance improvement models, preferably FOCUS-PDCA Knowledgeable of PI related Joint Commission standards
  • Participation in previous Joint Commission survey(s) required. PI related experience required
New Orleans
Date Posted
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