Director Accreditation & Regulation

AdventHealth Corporate

All the benefits and perks you need for you and your family:
Benefits from Day One
Career Development
Whole Person Wellbeing Resources
Mental Health Resources and Support

Our promise to you:

Joining AdventHealth is about being part of something bigger. It's about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.

Shift : Full-time; Monday-Friday

Job Location : Altamonte Springs, FL

The role you will contribute:

The Accreditation Director develops and implements organizational initiatives to support accreditation and regulatory activities. Responsibilities include collaboration with external accreditation and regulatory specialists as well as AdventHealth leaders and stakeholders to promote a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance.

The value you will bring to the team:

• Accreditation Leadership: Develop and implement strategies to achieve and maintain accreditation for healthcare programs and services. Act as the primary liaison with accreditation agencies, ensuring all accreditation needs are met.
• Continuous Readiness & Regulatory Compliance: Lead the ongoing evaluation, planning, and enhancement of infrastructure and processes to maintain continuous readiness for regulatory accreditation and hospital licensing. Identify and address potential vulnerabilities, escalating issues when necessary and leading resolution efforts for complex accreditation and compliance challenges. Provide insight on upcoming regulatory requirements along with exploring options for operationalizing requirements.
• Expertise in Regulatory Standards: Serve as a subject matter expert in The Joint Commission (TJC), Det Norske Veritas (DNV), and Centers for Medicare & Medicaid Services (CMS) standards. Collaborate with other regulatory experts to assess risks, and support the development, implementation, and monitoring of improvement initiatives. Provide detailed guidance on applications, Plans of Correction, and other required documentation, and offer interpretations of CMS Conditions of Participation (CoP).
• Stakeholder Communication: Maintain clear and ongoing communication with both internal teams and external accreditation bodies. Keep all relevant stakeholders informed of accreditation updates, regulatory changes, and compliance requirements.
• Education & Training Development: Create and maintain continuous readiness tools, reference materials, and educational resources to support ongoing compliance efforts. Lead initiatives such as tracers, mock surveys, and assessments to evaluate organizational adherence to regulatory standards. Provide regular training on accreditation standards and expectations.
• Quality Improvement Support: Promote continuous quality improvement by integrating accreditation-related goals with system-wide initiatives. Act as a key resource for quality improvement teams, helping them address deficiencies and track progress through performance metrics. Provide senior leadership with regular reports on accreditation status and performance.
• Survey Coordination: Assist with preparing for and attending onsite accreditation and regulatory surveys, including travel and in-person participation as needed.
• Certification Expansion: Expand accreditation expertise to support certification efforts where applicable, contributing to the organization's broader regulatory goals.
• Domestic Travel: The role will require the ability to travel for surveys and support.
• Additional Responsibilities: Perform other duties as assigned to support organizational goals and maintain accreditation standards.

Qualifications
The expertise and experiences you'll need to succeed:
Bachelor's Degree in relevant discipline 5 years equivalent experience Required
5+ Of clinical experience
Extensive experience in healthcare accreditation, compliance, and quality management
Comprehensive knowledge of CMS Conditions of Participation, TJC, and DNV
Progressive clinical and administrative experience, including development and implementation of specific accreditation, regulatory, safety and quality initiatives
Proficient computer skills, particularly Microsoft Office suite (Word, Excel, PowerPoint, PowerBI)
Demonstrates independent decision making and problem-resolution skills
Ability to communicate clearly, coordinate and work effectively with teams within/across organizations
Ability to manage multiple initiatives to achieve organizational goals
Results oriented and outcome driven
Joint Commission Connect
Premier Quality Advisor
Epic reporting tools (Cogito, Workbench, Clarity)

Preferred Qualifications:
Master's Degree in healthcare related field
CJCP - Certified Joint Commission Professional Preferred
CPHQ - Certified Professional in Healthcare Quality Preferred
CPPS - Certified Professional in Patient Safety Preferred