Accreditation Manager - RN

Job Description

Why Join Us?

• Competitive Compensation
• Comprehensive Medical, Dental, Vision & Life Insurance
• Generous Paid Time Off & Extended Illness Bank
• Matching 401(k) Retirement Plan
• Opportunities for Career Grown & Advancement
• Recognition & Reward Programs
• Exclusive Discounts & Perks*

Job Summary

The Manager, Quality is responsible for leading quality management initiatives and supporting compliance across the facility. This role ensures alignment with regulatory standards, promotes continuous improvement, and enhances patient care and operational efficiency. The Manager, Quality may focus on specialized areas such as clinical quality, coding quality, or process improvement, adapting quality strategies to meet the needs of different departments.

Essential Functions

• Develops, implements, and monitors quality management programs, ensuring alignment with department-specific goals and organizational standards.
• Collaborates with department leaders to identify and address quality improvement opportunities, developing initiatives to enhance performance and patient care.
• Conducts data analysis and quality assessments to identify trends, measure outcomes, and recommend improvements to support departmental objectives.
• Ensures compliance with regulatory and accreditation standards, conducting regular audits and coordinating readiness activities as needed.
• Provides training and education to staff on quality standards, policies, and best practices, fostering a culture of continuous improvement.
• Prepares and presents quality performance reports to department leaders and stakeholders, highlighting key metrics, progress, and opportunities for improvement.
• Manages and oversees quality documentation, ensuring accurate and comprehensive record-keeping for compliance and quality initiatives.
• Supports interdisciplinary quality improvement initiatives, working with cross-functional teams to drive efficient and effective care delivery.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Leadership Responsibilities

• Supervision and Staff Management
  • Provides leadership, mentorship and professional development opportunities for departmental staff.
  • Schedules employees to ensure effective use of resources. Consults with Director on staffing issues.
  • Conducts performance evaluations, sets goals and provides feedback to staff on their performance and development.
• Strategic Planning and Financial Oversight
  • Develops and manages departmental budget ensuring cost effective operations while maintaining high quality service.
  • Monitors expenditures, ensuring cost-effective delivery of services.
  • Evaluates and implements new technologies to enhance operational efficiency.
  • Develops and implements departmental policies and procedures and protocols to optimize quality and overall efficiencies.
• Quality Assurance and Regulatory Compliance
  • Ensures compliance with all relevant regulatory bodies. May oversee the accreditation process with relevant agencies ensuring that services meet or exceed industry standards.
  • Participates in audits, inspections and accreditation processes as applicable.
  • Follows established quality control practices to ensure accuracy, consistency and safety.
• Collaboration and Communication
  • Works closely with leadership teams to coordinate and improve service delivery.
  • Stays up-to-date with industry advancements, new technologies, and regulatory changes.
• Staff Responsibilities
  • May work in a staff role, when required. Ensures that duties and responsibilities are fulfilled while meeting all competencies established for that job.

Qualifications

• Bachelor's Degree in relevant field required or
• Four (4) plus years of direct experience in lieu of a Bachelor's degree required
• Master's Degree preferred
• 2-4 years of experience in closely related field with Bachelor's degree required
• 2-4 years of previous leadership experience preferred

Knowledge, Skills and Abilities

• Strong leadership, organizational, and communication skills.
• Ability to collaborate with interdisciplinary teams and manage cross-functional relationships.
• Foster a positive work environment that promotes teamwork, professionalism, and continuous improvement.
• Communicate effectively with leadership, team members, and stakeholders.
• Ability to work effectively with others, delegate responsibilities, and independently manage tasks while meeting established deadlines.
• Problem-solving and critical thinking skills.
• In depth knowledge of industry best practices and regulatory compliance (if applicable).
• Strong organizational and time management skills.
• Proficiency with Google and Microsoft platforms, healthcare software systems, and data analysis tools. 

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required
• CPHQ - Certified Professional in Healthcare Quality preferred

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