Accreditation and Governance Specialist

Centerstone of Florida; Bradenton (FL); On-site; USD 70,000 - 100,000; Full time

Job summary

Centerstone of Florida seeks an Accreditation and Governance Specialist to promote continuous survey readiness, regulatory compliance, and consistent implementation of accreditation standards across markets and service lines. You will partner with operational leaders to interpret standards, conduct mock surveys and tracers, monitor corrective actions, and prepare for surveys.

This role serves as a subject matter expert on accreditation requirements and collaborates with Clinical Excellence, Risk

Qualifications

• Bachelor's degree in the specified fields
• Three years of healthcare quality or related experience
• Experience in accreditation surveys
• Strong written and verbal communication
• Travel as required

Responsibilities

• Support enterprise accreditation readiness across markets and service lines.
• Conduct mock surveys, tracers, and readiness assessments.
• Interpret accreditation standards for operational leaders.
• Prepare for accreditation and regulatory surveys including document review.
• Monitor compliance and report risks to leadership.
• Develop and monitor corrective action plans.
• Educate and consult on accreditation standards.
• Collaborate with governance and quality departments.
• Maintain documentation for readiness activities.
• Travel as required

Skills

Accreditation knowledge

Regulatory compliance

Project management

Communication skills

Detail orientation

Education

Bachelor's degree in Social Work, Health and Human Services, Healthcare Administration, Nursing, Public Health

Tools

Microsoft Office

Electronic documentation systems

Job description

Position Summary

The Accreditation and Governance Specialist supports Centerstone's enterprise Accreditation & Quality Governance program by promoting continuous survey readiness, regulatory compliance, and consistent implementation of accreditation standards across all markets and service lines. This position partners closely with operational leaders to interpret accreditation standards, conduct mock surveys and tracers, monitor corrective action plans, and prepare the organization for regulatory and accreditation surveys. The Accreditation and Governance Specialist serves as a subject matter resource on accreditation requirements and collaborates with Clinical Excellence, Clinical Risk Management, Patient Voice & Experience, and Policy Governance to strengthen organizational quality and regulatory compliance.

Essential Duties and Responsibilities

• Support enterprise accreditation readiness initiatives across all Centerstone markets and service lines.
• Conduct mock surveys, tracers, and readiness assessments to evaluate compliance with accreditation standards and organizational policies.
• Partner with operational leaders to identify opportunities for improvement and strengthen continuous survey readiness.
• Assist with preparation for accreditation and regulatory surveys, including document review, evidence collection, and survey logistics.
• Monitor compliance with accreditation standards and communicate identified risks or deficiencies to leadership.
• Assist in developing and monitoring corrective action plans resulting from accreditation surveys, mock surveys, tracers, and regulatory reviews.
• Collaborate with operational leaders to ensure timely completion of corrective actions and ongoing compliance activities.
• Provide education and consultation regarding accreditation standards, regulatory expectations, and survey readiness.
• Assist with interpretation of accreditation standards and communicate updates to operational leaders.
• Participate in enterprise readiness committees and quality governance activities.
• Collaborate with Policy Governance to ensure policies and procedures align with accreditation standards and regulatory requirements.
• Collaborate with Clinical Excellence to incorporate findings from chart reviews, tracers, and clinical quality evaluations into survey readiness efforts.
• Collaborate with Operations/Clinical management to identify trends that may impact accreditation readiness or regulatory compliance.
• Completes activities associated to SAMSHA survey
• Completes activities necessary to ensure certification of Centerstone locations in National Health Services Corps (NHSC) and the opportunity for enrollment of Centerstone staff into NHSC programs
• Assists in activities to ensure compliance with Federal Rule 1557 of Affordable Care Act regarding non-discrimination activities.
• Maintain documentation and records related to accreditation readiness activities.
• Participate in enterprise quality improvement initiatives as assigned.
• Represents the department on internal organizational committees and functions. Acts as a representative of Centerstone externally with key stakeholders relevant to work of the department.
• Periodic travel may be required to support organizational priorities, including leadership collaboration, incident response activities, staff development, and other Clinical Risk Management initiatives. Travel expectations will vary based on organizational needs.
• Perform other duties as assigned.

Supervisory Responsibilities

This position does not have supervisory responsibilities.

Knowledge, Skills and Abilities

• Working knowledge of healthcare accreditation standards and survey processes.
• Knowledge of behavioral healthcare operations preferred.
• Knowledge of continuous survey readiness principles.
• Ability to interpret regulatory and accreditation requirements.
• Strong organizational and project management skills.
• Excellent written and verbal communication skills.
• Strong facilitation and relationship-building abilities.
• Strong attention to detail.
• Ability to prioritize multiple projects and deadlines.
• Ability to analyze compliance gaps and recommend practical solutions.
• Proficiency with Microsoft Office applications and electronic documentation systems.

Minimum Qualifications

Education

Bachelor's degree in Social Work, Health and Human Services, Healthcare Administration, Nursing, Public Health, or a related field.

Experience

Three (3) years of experience in healthcare quality, accreditation, compliance, clinical operations, or related healthcare field. Experience participating in accreditation surveys, mock surveys, regulatory reviews, or qu