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Job Title
Senior Director of Accreditation
Location
Cleveland
Facility
Cleveland Clinic Main Campus
Department
Office of Accreditation Corporate-Clinical and Operational Improvement
Job Code
T98654
Shift
Days
Schedule
8:00am-5:00pm
Job Summary
Job Details
Join Cleveland Clinic’s Main Campus where research and surgery are advanced, technology is leading-edge, patient care is world class and caregivers are family. Here, you will work alongside a passionate and dedicated team, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.
As Senior Director of Accreditation, you will lead the strategy, implementation, and oversight of accreditation and regulatory readiness across Cleveland Clinic’s enterprise hospitals in Ohio and Florida. In collaboration with the Senior Director of Regulatory Affairs, you will oversee accreditation activities before, during, and after surveys conducted by agencies including The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and Ohio Department of Health (ODH). You will serve as an enterprise resource and consultant, lead on-site survey activities, and build strong partnerships with clinical, operational, and executive leaders to advance a proactive, consistent approach to regulatory readiness, safety, quality, and continuous improvement. You will also support acquisition due diligence and onboarding activities and provide regulatory and accreditation guidance for Cleveland Clinic’s international initiatives.
This is an exciting opportunity to lead a talented team of approximately 33 caregivers and shape the future of accreditation and regulatory readiness across the organization. You will have a pivotal role in strengthening the enterprise approach, developing a cohesive, high-performing team, and embedding a culture of continuous improvement into everyday operations. The ideal candidate will bring strategic vision, exceptional relationship-building skills, and a passion for developing people and leading meaningful organizational change.
A caregiver in this role works Monday through Friday from 8:00 a.m. – 5:00 p.m., with on-call responsibilities and 5%–10% travel requirements.
A caregiver who excels in this role will:
- Effectively direct activities related to TJC including application submission, survey planning and logistics, post-survey Evidence of Standards Compliance (ESC) and annual intracycle monitoring.
- Direct continuous readiness activities including Continuous Readiness Rounds, Tracer Teams, Mock Surveys, Intranet Accreditation site content, and educational materials and activities.
- Leas and coordinate regulatory on-site surveys, including but not limited to TJC, ODH and CMS.
- Responsible for effective post survey action plans and formal responses to accrediting and regulatory agencies.
- Maintain current knowledge of accreditation and compliance issues affecting healthcare.
- Stay abreast of changes in TJC standards, JCI (Joint Commission International) Standards, Ohio Administrative Code and Ohio Regulatory Code, CMS Conditions for Coverage and Conditions of Participation requirements and standards.
- Communicate standard changes to executive leadership and others in the organization who need to know.
- Collaborate with Enterprise Quality Departments and organization Institutes to ensure Cleveland Clinic is compliant with accreditation standards and regulatory requirements.
- Other duties as assigned.
Minimum qualifications for the ideal future caregiver include:
- Bachelor’s Degree in health-related field
- Certifications required: Healthcare Accreditation Certified Professional (HACP) or Certified Joint Commission Professional (CJCP) (If applicant does not have one of these certifications, they will need to achieve certification within one year)
- Ten years of health care experience in a clinical discipline including at least five years of accreditation experience and five years of leadership/management experience
- Specific experience related to accreditation and regulatory bodies, such as CMS and state licensing agencies
- In-depth knowledge of accrediting and regulatory standards
- Demonstrated ability to interpret standards, serve as a subject matter expert and communicate information to all levels in the organization
- Ability to manage employees and prioritize and manage multiple tasks simultaneously
- Demonstrated leadership skills
- Excellent communication skills
Preferred qualifications for the ideal future caregiver include:
- Master’s Degree
- Experience in International accreditation
- Demonstrated experience leading accreditation, regulatory, quality, or patient safety programs within a complex healthcare organization
- Experience leading and developing multidisciplinary teams, preferably across multiple hospitals or markets
- Demonstrated success leading organizational change, standardizing processes, and improving operational performance
- Strong executive presence and ability to influence and collaborate with senior clinical and operational leaders
- Experience applying continuous improvement methodologies to achieve sustainable results
- Ability to balance strategic leadership with operational execution
Physical Requirements:
- Manual dexterity to operate office equipment
- Ability to lift and transport up to 15 pounds
- Requires extended periods of standing, walking and sitting.
- Normal or corrected vision and hearing to normal range.
Personal Protective Equipment:
- Donning and doffing appropriate PPE when performing tracers or visiting patient care areas.
The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.
Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.
Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility.
If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/
Please review the Equal Employment Opportunity poster.
Cleveland Clinic is pleased to be an equal employment opportunity employer.
