Accreditation & Compliance Director

Bayhealth; Dover (DE); On-site; USD 136,000 - 211,000; Full time

Benefits offered by this job

Generous Paid Time Off

Matching 401(k) Plans

Health, Dental, and Vision

Disability and Life Insurance

On Site Child Care

Educational Reimbursement

Health Care and Dependent Care Flex Sp

Voluntary Benefits

Job summary

Bayhealth Medical Center in Dover, DE, seeks an Accreditation Services Director to lead regulatory and accreditation efforts across the system, including oversight of standard processes and readiness for external surveys.

This role serves as the chief liaison for TJC, DDHSS and CMS, guiding staff education, policy review, corrective actions, budgeting, and external consultant coordination to ensure ongoing compliance and readiness.

Qualifications

• Five (5) years leading accreditation and regulatory processes including TJC, CMS and state licensure.

Responsibilities

• Provide oversight of standard processes across Bayhealth entities for external accreditation and regulatory requirements.
• Act as chief liaison for TJC, DDHSS and CMS and coordinate survey-related activities.
• Oversee education, policy/procedure review and corrective action plans.
• Manage budgeting, staffing, and performance of Accreditation Services staff.
• Coordinate use of external consultants and mock surveys to assure readiness.

Skills

Regulatory leadership

Education

Bachelor's Degree in Nursing (BSN)

Master's Degree in health-related field

Job description

Bayhealth Medical Center in Dover, DE, seeks an Accreditation Services Director to lead regulatory and accreditation efforts across the system, including oversight of standard processes and readiness for external surveys.

This role serves as the chief liaison for TJC, DDHSS and CMS, guiding staff education, policy review, corrective actions, budgeting, and external consultant coordination to ensure ongoing compliance and readiness.