Accreditation Manager

Job Summary:
Under the direction of the Director of Risk Regulatory and Accreditation, the Accreditation Manager plays a vital role in coordinating, overseeing, and planning the hospital's compliance with accreditation standards. This position ensures adherence to requirements established by accrediting bodies such as the American College of Cardiology and DNV-GL. The Accreditation Manager organizes workflows, sets priorities, assigns tasks, enforces deadlines, and makes decisions through analytical and innovative problem-solving within established guidelines.

Essential Responsibilities:

• Coordinate the hospital's adherence to accreditation standards across multiple programs, including Chest Pain, Cath Lab, Heart Failure, and Comprehensive Stroke.
• Develop and implement strategies to improve CMS quality metrics, such as 30-day readmission rates and mortalities, aligning with the hospital's Destination 2027 plan.
• Serve as a knowledge resource for accreditation programs, ensuring compliance, knowledge retention, and sustainability of program requirements.
• Analyze data, monitor performance, and identify areas for improvement in collaboration with hospital professionals and medical staff.
• Lead performance improvement initiatives, leveraging research methodologies and statistical analysis to support quality improvement efforts.
• Maintain effective reporting and monitoring systems to ensure quality outcomes and regulatory compliance.

Minimum Qualifications:

Licensure/Certification:

• Licensed Registered Nurse (RN) in the state of Indiana.

Education:

• Bachelor’s degree in a healthcare-related field required (Master’s degree preferred).

Experience:

• Minimum of two years’ experience in performance improvement, accreditation, quality, or leadership.

Required Knowledge, Skills, and Abilities:

• Strong knowledge of research methodologies, organizational systems, and performance improvement principles within a healthcare environment.
• Proficiency with software systems for data retrieval, analysis, and reporting.
• Excellent analytical, organizational, and problem-solving skills, with attention to detail and accuracy.
• Ability to present complex technical information clearly and effectively to diverse audiences.
• Strong interpersonal and communication skills (both verbal and written) to interact effectively with internal and external stakeholders.
• Demonstrated leadership abilities, including team cohesion and collaboration across multidisciplinary teams.
• Experience in statistical analysis, data systems management, and quality improvement strategies.

What we offer:
Competitive Pay - Medical, Dental, Vision, & Life Insurance - Generous Paid Time Off (PTO) - Extended Illness Bank (EIB) - Tuition Reimbursement - Matching 401(k) - Opportunities for Career Advancement - Rewards and Recognition Programs - Additional Discounts and Perks*

This role is integral to achieving the hospital's quality and accreditation goals, sustaining compliance with hundreds of accreditation requirements, and supporting the long-term success of key programs. The ideal candidate will have a strong commitment to excellence in healthcare quality and an ability to drive meaningful improvements.

INDLEAD
To apply, please email laura_peterson2@chs.net