Accreditation and Governance Specialist

Centerstone; Tennessee; Presencial; USD 51.000 - 71.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Medical, dental & vision coverage

401(k) with company match

PTO & paid holidays

AD&D, Life & LTD insurance

Employee Resource Groups

Continuing education opportunities

Employee Assistance Program

Descripción de la vacante

Centerstone is seeking an Accreditation and Governance Specialist to promote continuous survey readiness and ensure alignment with accreditation standards across markets and service lines. The role partners with Clinical Excellence, Risk Management, Patient Experience, and Policy Governance to strengthen regulatory compliance.

The specialist will conduct mock surveys, tracers, and readiness assessments, assist with corrective action plans, and prepare for surveys.

Formación

• Bachelor's degree in a related field required.
• Minimum of 3 years in healthcare quality, accreditation, compliance, or related field.
• Experience with accreditation surveys, mock surveys, regulatory reviews, or quality improvement preferred.

Responsabilidades

• Support enterprise accreditation readiness across markets and service lines.
• Conduct mock surveys, tracers, and readiness assessments for compliance.
• Collaborate with leaders to identify improvement opportunities and ensure timely corrective actions.
• Assist in preparation for accreditation and regulatory surveys including document review and evidence collection.
• Monitor compliance and report risks or deficiencies to leadership.
• Provide education on accreditation standards and survey readiness.

Conocimientos

Accreditation standards

Survey readiness

Regulatory compliance

Project management

Written communication

Interpersonal skills

Microsoft Office

Educación

Bachelor's degree in Healthcare Administration

Descripción del empleo

Centerstone is among the nation’s leading nonprofit behavioral health systems with thousands of employees dedicated to delivering care that changes people’s lives. A dynamic, well-established organization, we offer rewarding opportunities to serve all ages in a variety of settings. Come talk to us about joining the Centerstone team! 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 quality improvement activities preferred.

Licenses and Certifications

• Preferred: Certified Professional in Healthcare Quality (CPHQ).
• Licensed healthcare professional preferred, when applicable.

Preferred Qualifications

• Experience in behavioral healthcare.
• Experience within a large multi-site or multistate healthcare organization.
• Experience supporting Joint Commission, CARF, CMS, or state licensing surveys.
• Experience conducting mock surveys or tracer activities.
• Experience interpreting accreditation standards and regulatory requirements.
• Experience collaborating with interdisciplinary operational teams.
• Experience developing or monitoring corrective action plans.

Physical and Work Environment Requirements

Work is performed in an office, clinical, residential, and/or community-based environment depending on role and assignment. The position may involve routine use of office, clinical, or electronic systems and equipment. Duties may require prolonged periods of sitting, standing, walking, and working at a computer. Work hours may include evenings, weekends, holidays, or extended shifts based on program needs. This position is classified as sedentary work. Sedentary work involves exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

Program and State-Specific Requirements (When Applicable)

N/A Disclaimer The statements herein are intended to describe the general nature and level of work performed by individuals assigned to this position. They are not intended to be an exhaustive list of all responsibilities, duties, and skills required. Duties and responsibilities may change at any time with or without notice.

Time Type: Full time Pay Range: $50,700.00--$71,100.00

Delivering care that changes people's lives starts with our employees.

Benefits

• Medical, dental, and vision health coverage
• Flexible Spending and Health Savings Accounts
• 403b retirement plan with company match
• Paid time off and ten paid holidays
• AD&D Insurance, Life Insurance, and Long Term Disability (company paid)
• Employee Resource Groups
• Continuing education opportunities
• Employee Assistance Program

Equal Opportunity Statement

Centerstone is an equal opportunity employer. Employment at Centerstone is based solely on a person's merit and qualifications directly related to professional competence. We treat all clients and colleagues with dignity and respect. At Centerstone, we use our values as a guide for what we do. Respect, Expertise, Integrity and Empowerment are at the heart of every interaction at Centerstone, and particularly rooted in our Culture. Our approach to culture is to create an environment that encourages, supports and celebrates the voices and experiences of our employees. We are committed to a culture of empowerment, respect, integrity and expertise that powers our innovation and connects us to each other, our clients and the communities we serve.

Company Overview

Centerstone is also committed to a strong culture of quality and safety, celebrating role-models who champion best practices for quality, clinical risk, and patient safety. Centerstone is a nonprofit health system providing mental health and substance use disorder treatments. Services are available nationally through the operation of outpatient clinics, residential programs, the use of telehealth and an inpatient hospital. Centerstone also features specialized programs for the military community, therapeutic foster care, children’s services and employee assistance programs. Centerstone’s Research Institute provides guidance through research and technology, leveraging the best practices for use in all our communities. Centerstone’s Foundation secures philanthropic resources to support the work and mission of delivering care that changes people’s lives.