At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

                        

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

                                    

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

7:30am-5:00pm

                       

Job Summary

                         

Job Details

Job Responsibilities:

• Effectively directs activities related to TJC including application submission, survey planning and logistics, post-survey Evidence of Standards Compliance (ESC) and annual intercycle monitoring.
• Directs continuous readiness activities including Continuous Readiness Rounds, Tracer Teams, Mock Surveys, Intranet Accreditation site content, and educational materials and activities.
• Leads and Coordinates 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.
• Maintains current knowledge of accreditation and compliance issues affecting healthcare.
• Stays 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.
• Collaborates with Enterprise Quality Departments and organization Institutes to ensure Cleveland Clinic is compliant with accreditation standards and regulatory requirements.
• Other duties as assigned.

Education:

• Bachelor’s Degree in health-related field required
• Master’s Degree preferred

Certifications:

• 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 1 year.

Competencies (Complexity of Work):

• In-depth knowledge of accrediting and regulatory standards with demonstrated ability to interpret standards, serve as a subject matter expert and communicate information to all levels in the organization.
• Demonstrated leadership skills with the ability to manage employees and prioritize and manage multiple tasks simultaneously.
• Excellent communication skills to effectively interact with all levels of Caregivers, from senior leaders to front-line caregivers.

Work Experience:

• Experience in International accreditation preferred
• Minimum ten years health care experience in a clinical discipline including at least five years accreditation experience and 5 years leadership/management experience.
• Specific experience related to accreditation and regulatory bodies, such as CMS and state licensing agencies.

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 tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. All offers of employment are follwed by testing for controlled substances and nicotine. All new caregivers must clear a nicotine test within their 90-day new hire period. Candidates for employment who are impacted by Cleveland Clinic Health System's Smoking Policy will be permitted to reapply for open positions after one year.

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. 

Please review the Equal Employment Opportunity poster. 

                  

Cleveland Clinic Health System is pleased to be an equal employment employer: Women / Minorities / Veterans / Individuals with Disabilities