Facility: North Fulton Hospital

Manager, Accreditation & Licensure:
Are you passionate about healthcare quality and regulatory excellence? We are seeking a dynamic Manager of Accreditation & Licensure to lead our hospital’s accreditation and licensure efforts. Under the direction of the Director of Quality & Safety, you will be the organization’s expert on The Joint Commission (TJC), CMS, and other accreditation standards.

In this role, you will drive continuous survey readiness, ensuring compliance across hospital, outpatient, home care, and hospice settings. You will also play a key role in education and coaching, helping teams understand and meet accreditation requirements.

Key Responsibilities:

Continuous Readiness & Survey Leadership

• Oversee and coordinate all accreditation and regulatory survey activities, including TJC, CMS, and state regulatory surveys.
• Lead mock surveys and tracer activities, leveraging electronic databases to track and report findings.
• Identify high-risk compliance areas, develop proactive strategies, and implement process improvements.
• Ensure action plans for deficiencies are executed on time and monitored for effectiveness.
• Communicate survey readiness successes and potential barriers with hospital leadership and medical staff.

Regulatory Compliance & Standards Management

• Monitor and interpret updates to TJC, CMS, OSHA, NCCHC, and other relevant standards.
• Serve as a subject matter expert, providing guidance on compliance requirements.
• Act as a task force leader for key accreditation initiatives and regulatory projects.

Education & Program Leadership

• Develop and implement accreditation training programs for hospital teams.
• Foster a culture of continuous readiness and regulatory excellence through education and team collaboration.
• Guide and support the Continuous Survey Readiness Committee.

Data Collection & Analysis

• Utilize Accreditation Management software to track trends and generate reports.
• Analyze and interpret survey data to identify improvement opportunities.
• Provide insightful reporting to hospital leadership and accreditation committees.

Required Qualifications:

Education:

• Bachelor’s degree in nursing or a healthcare-related field Required.
• MBA or Master’s Degree in a healthcare-related field Preferred.

Certifications:

• Additional TJC certifications preferred.

Experience:

• Minimum 5 years of experience in healthcare, nursing, or clinical practice.
• Minimum 5 years of experience managing hospital accreditation and licensure programs (TJC, CMS).

Skills & Competencies:

• Strong analytical skills with the ability to interpret and present data effectively.
• Exceptional organizational and interpersonal skills—able to work independently and collaboratively.
• Outstanding written and verbal communication abilities.
• High level of professionalism, discretion, and confidentiality.
• Proficiency in Microsoft Office and accreditation management software.
• Skilled in problem-solving, consensus-building, and process improvement.