Manager, Accreditation

1 week ago

Cambridge MA United States Cambridge Health Alliance Full time

Location: 1035 Cambridge Street

Work Days: M-F with some flexibility required

Category: Professional and Management

Department: Risk Management

Job Type: Full time

Work Shift: Day

Hours/Week: 40

Union Name: Non Union


The Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate preventable harm for all patients and staff, provide high value, equitable, evidence-based care, create an excellent care experience and to develop institutional capacity in improvement science and promote data driven decision making. Join our talented team to contribute towards the mission of our organization.

Under the direction of the Senior Director of Risk Management & Patient Safety, and working collaboratively with Quality and Safety leadership, the Manager, Accreditation & Regulatory Compliance leads efforts to ensure continual organizational compliance and ongoing readiness with clinical quality and patient safety standards and regulations required by The Joint Commission, Massachusetts Department of Public Health and Center for Medicare and Medicaid Services. In this role the Manager, Accreditation & Regulatory Compliance proactively plans, implements, coordinates and continually improves the Cambridge Health Alliance's (CHA) efforts related to compliance, accreditation, and licensure requirements.

Key Job Responsibilities:

  • Responsible for the overarching development and maintenance of a continuous readiness program across the institution for all accreditation and regulatory oversight bodies.

  • Serves as the organizational expert for The Joint Commission, DMH, DPH and CMS standards, regulations and conditions of participation.

  • Responsible for the interpretation and communication of regulatory and licensing requirements throughout the organization.

  • Acquires and demonstrates expertise in specialized accreditation programs such as the Commission on Cancer (CoC), Bureau of Substance Abuse Services (BSAS), Commission for the Accreditation of Birth Centers, TJC and MassHealth Health Equity standards, NCQA Certification, Utilization Review Accreditation Commission (URAC), among others.

  • Provides education and consultation to administrative, operational, and clinical leadership, staff and faculty throughout CHA regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods.

  • Provides informal consultation and advice to assist administrative and clinical leaders and their departments in improving performance.

  • Facilitates development of tools, policies, and procedures, and learning aids to promote compliance with standards.

  • Provides timely communication regarding new and revised TJC, DMH, DPH, and CMS standards and interpretations to administrative and clinical leadership and staff.

  • Works closely and builds effective working relationships with accreditation and regulatory agencies, i.e.The Joint Commission, DMH, DPH and CMS.

  • Responsible for all aspects of the plan to ensure continual readiness with the clinical regulatory and accreditation requirements of the TJC, DMH, DPH and CMS. Serves as a member of the Patient Safety Committee and other committees as deemed appropriate.

Qualifications:

  • Baccalaureate Degree, BSN highly preferred. Master's Degree with a healthcare focus is also highly preferred.

  • 3-5 years of experience with The Joint Commission, DPH and other regulatory requirements and survey processes.

  • Strong working knowledge of all applicable TJC, CMS, DPH and DMH standards to support the organization's continual regulatory readiness.

  • Outstanding team player with the ability to self-initiate and independently start and complete projects without direction .

  • Ability to develop effective relationships with a broad array of people from diverse backgrounds.

  • Strong interpersonal skills; ability to establish supportive, collegial relationships.

  • Superior organizational skills to manage a large volume of incoming data, information, reports, etc. in paper and electronic formats.

  • Ability to create and deliver appealing and compelling presentations to a variety of audiences including clinicians, staff, faculty, administration and governance groups.

  • Demonstrated skill in change management and quality improvement.

  • Knowledge of clinical terminology.

  • Ability to learn and effectively use computer software, such as electronic health records and data entry.



In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.

Cambridge Health Alliance brings Care to the People - including your neighbors, friends and family. Our local hospitals and care centers serve our vibrant, diverse communities, and play an integral role in improving health. As passionate advocates for the underserved, we actively partner with our communities to take on challenging public health issues, and conduct important research to help reduce barriers to care. We believe that everyone deserves access to high quality, convenient health care. This is why our employees believe in where they work and why many build long, rewarding careers at CHA.

Healthcare is changing rapidly. CHA has a strategic plan that charts a proactive course for our future. It is built on a vision of equity and excellence for everyone, every time. It also recognizes that our workforce is our most valuable asset and prioritizes competitive salaries, benefits and professional development opportunities for employees. The strategic plan is changing the way we provide care and improving the health and experience of our patients; we are looking for smart, committed, compassionate people who want to be part of making our vision of better health and equity a reality.

At CHA, you can believe in where you work and go home every day knowing you made a difference. Join our team and help us bring Care to the People.

  • Manager, Accreditation

    2 weeks ago

    Cambridge, MA, United States Cambridge Health Alliance Full time

    Location: 1035 Cambridge Street Work Days: M-F with some flexibility required Category: Professional and Management Department: Risk Management Job Type: Full time Work Shift: Day Hours/Week: 40 Union Name: Non Union The Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate preventable harm...

  • Manager, Accreditation

    1 month ago

    Cambridge, MA, United States Cambridge Health Alliance Full time

    Location: 1035 Cambridge Street Work Days: M-F with some flexibility required  Category: Professional and Management  Department: Risk Management  Job Type: Full time  Work Shift: Day Hours/Week: 40Union Name: Non UnionThe Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate...

  • Manager, Accreditation

    1 week ago

    Cambridge, United States Cambridge Health Alliance Full time

    Location:1035 Cambridge StreetWork Days:M-F with some flexibility requiredCategory:Professional and ManagementDepartment:Risk ManagementJob Type: Full timeWork Shift: DayHours/Week: 40Union Name: Non UnionThe Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate preventable harm for all...

  • Manager, Accreditation

    1 month ago

    Cambridge, United States Cambridge Health Alliance Full time

    Location: 1035 Cambridge Street Work Days: M-F with some flexibility required  Category: Professional and Management  Department: Risk Management  Job Type: Full time  Work Shift: Day Hours/Week: 40Union Name: Non UnionThe Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate...

  • Manager, Accreditation

    1 month ago

    Cambridge, United States Cambridge Health Alliance Full time

    Location: 1035 Cambridge Street Work Days: M-F with some flexibility required  Category: Professional and Management  Department: Risk Management  Job Type: Full time  Work Shift: Day Hours/Week: 40Union Name: Non UnionThe Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate...

  • Manager, Accreditation

    1 month ago

    Cambridge, United States Cambridge Health Alliance Full time

    Location: 1035 Cambridge Street Work Days: M-F with some flexibility required  Category: Professional and Management  Department: Risk Management  Job Type: Full time  Work Shift: Day Hours/Week: 40Union Name: Non UnionThe Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate...

  • Manager, Accreditation

    1 month ago

    Cambridge, United States Cambridge Health Alliance Full time

    Location: 1035 Cambridge Street Work Days: M-F with some flexibility required  Category: Professional and Management  Department: Risk Management  Job Type: Full time  Work Shift: Day Hours/Week: 40Union Name: Non UnionThe Quality and Safety Department serves as a resource center to the organization to cultivate a culture of safety, eliminate...

  • Accreditation and Regulatory Specialist

    4 weeks ago

    Boston, MA, United States Boston Medical Center (BMC) Full time

    Job DescriptionPosition SummaryUnder the direction of the Senior Director, Accreditation & Regulatory and working collaboratively, the Accreditation and Regulatory Specialist (Nurse) leads efforts to ensure continual organizational compliance and ongoing readiness with clinical quality and patient safety standards and regulations required by The Joint...

  • Accreditation Manager

    2 days ago

    San Francisco, CA, United States CALEA Full time

    The Accreditation manager is responsible for the day-to-day management of the UCSF Police Department accreditation process for the Commission on Accreditation for Law Enforcement Agencies, (CALEA) and the International Association of Campus Law Enforcement Administrators, (IACALEA) and the development of processes to meet and exceed reaccreditation...

  • Accreditation Manager

    2 days ago

    San Francisco, CA, United States CALEA Full time

    The Accreditation Manager is responsible for the day-to-day management of the UCSF Police Department accreditation process for the Commission on Accreditation for Law Enforcement Agencies (CALEA) and the International Association of Campus Law Enforcement Administrators (IACLEA), as well as the development of processes to meet and exceed reaccreditation...

  • Director, Accreditation

    2 days ago

    Sarasota, FL, United States New College of Florida Full time

    Description This position has primary responsibility to collaboratively support faculty and staff in preparing meaningful assessment plans and reports. Examples of Duties Plans, organizes, and coordinates college-wide strategic, comprehensive, and ongoing assessment programs, projects, and activities measuring student learning and institutional...

  • Senior Accreditation Specialist

    4 weeks ago

    Titusville, FL, United States Parrish Healthcare Full time

    Department: Risk Management/QRM Schedule/Status: 8am-430pm; Full Time Standard Hours/Week: 40 General Description: Under the general supervision of the Quality Manager, the Accreditation Coordinator is primarily responsible for coordinating and responding to initiatives related to the accreditation programs for The Joint Commission (TJC), Agency for...

  • Senior Accreditation Specialist

    2 months ago

    Titusville, FL, United States Parrish Healthcare Full time

    Department:Risk Management/QRMSchedule/Status:8am-430pm; Full Time Standard Hours/Week:40 General Description:Under the general supervision of the Quality Manager, the Accreditation Coordinator is primarily responsible for coordinating and responding to initiatives related to the accreditation programs for The Joint Commission (TJC), Agency for Healthcare...

  • Senior Accreditation Specialist

    2 months ago

    Titusville, FL, United States Parrish Healthcare Full time

    Department:Risk Management/QRMSchedule/Status:8am-430pm; Full Time Standard Hours/Week:40 General Description:Under the general supervision of the Quality Manager, the Accreditation Coordinator is primarily responsible for coordinating and responding to initiatives related to the accreditation programs for The Joint Commission (TJC), Agency for Healthcare...

  • Senior Accreditation Specialist

    4 weeks ago

    Titusville, FL, United States Parrish Healthcare Full time

    Job DescriptionDepartment:Risk Management/QRMSchedule/Status:8am-430pm; Full TimeStandard Hours/Week:40General Description:Under the general supervision of the Quality Manager, the Accreditation Coordinator is primarily responsible for coordinating and responding to initiatives related to the accreditation programs for The Joint Commission (TJC), Agency for...

  • Sr. Accreditation Specialist

    4 weeks ago

    Goodyear, AZ, United States United Aviate Academy Full time

    The Sr. Accreditation Specialist will promote a culture of assessment by working closely with faculty, program coordinators, staff, and students to systematically define and assess student learning outcomes at the program and course level, which supports the accreditation process and the United Aviate Academy program requirements. Using appropriate programs...

  • Accreditation and Regulatory Consultant

    2 days ago

    Columbus, OH, United States Nationwide Children's Hospital Full time

    Overview The Accreditation and Regulatory Consultant assists in the evaluation, implementation, monitoring, and improvement of compliance with internal and external regulatory requirements and policies for the organization. This position works on a multi-disciplinary team and shares best practices among all areas. Schedule: Monday-Friday (1st shift) Fully...

  • Vice President, Certification

    3 days ago

    Washington, DC, United States CSBS Full time

    Vice President, Certification & Accreditation CSBS Corporate, 1300 I Street NW, Washington, District Of Columbia, United States of America Req #250 Saturday, September 21, 2024 The Vice President for Certification & Accreditation (Vice President) is responsible for overseeing the administration and ongoing development of CSBS’ Examiner...

  • Lab Program Manager Lab Quality Safety Accreditation

    2 weeks ago

    Edgewood, KY, United States St. Elizabeth Healthcare Full time

    Engage with us for your next career opportunity. Right Here.Job Type:RegularScheduled Hours: 40Job Summary:The Program Manager Laboratory Quality, Safety, Accreditation formulates strategic goals, assigns objectives, manages projects, reviews/analyzes data, and establishes standards of practice with effective monitors for the Laboratory System and Preferred...

  • Clinical Accreditation Specialist

    4 weeks ago

    Elmira, NY, United States Arnot Health Full time

    Job DescriptionMAIN FUNCTION:The Clinical Accreditation Specialist acts as a consultant on interpretation of regulatory standards, including The Joint Commission and Centers for Medicare and Medicaid Services (CMS); ensures a constant state of readiness; advises on policy development, educates health care providers on the relevance of standards supporting a...