Accreditation Manager

Socket.dev; Atlanta (GA); On-site; USD 90,000 - 120,000; Full time

Job summary

Emory Healthcare is hiring an Accreditation Manager to provide OU direction and oversight for regulatory and accreditation compliance. This role leads readiness activities for multiple certifications and works with OU clinical, operational, and executive leaders to drive sustained readiness, standardization, and continuous improvement aligned with the Always Patient Ready mission.

Responsibilities include planning tracers, real-time coaching, identifying gaps and risks, and supporting surveys.

Qualifications

• Knowledge of Quality Improvement methodologies, group facilitation, project management, and healthcare regulatory and event reporting requirements.

Responsibilities

• Provide OU-level oversight for accreditation and regulatory compliance with TJC, state, and federal agencies.
• Plan, lead, and conduct tracers and readiness assessments.
• Educate leaders and frontline staff on standards interpretation and tracer methodology.
• Serve as a consultant on regulatory compliance, process redesign, and risk mitigation.
• Collaborate with leadership to sustain processes and improvements for high reliability and readiness.
• Track and report readiness activities, tracer findings, and corrective action status.

Skills

Quality Improvement methodologies

Group facilitation

Project management

Healthcare regulatory and event-report

Education

Bachelor's degree in health-related field

Job description

Be inspired. Be rewarded. Belong. At Emory Healthcare.

At Emory Healthcare we fuel your professional journey with better benefits, valuable resources, ongoing mentorship and leadership programs for all types of jobs, and a supportive environment that enables you to reach new heights in your career and be what you want to be. We provide:

• Comprehensive health benefits that start day 1

• Student Loan Repayment Assistance & Reimbursement Programs

• Family-focused benefits

• Wellness incentives

• Ongoing mentorship, development, and leadership programs

• And more

Description

Overview:

The Accreditation Manager provides Operating Unit (OU) direction, oversight and support for regulatory and accreditation compliance.

This role leads accreditation readiness activities and supports multiple certification and licensure programs. The Accreditation Manager partners with OU clinical, operational, and executive leaders to drive sustained readiness, standardization, and continuous improvement aligned with the organization's Always Patient Ready mission.

Primary duties and responsibilities:

• Accreditation & Regulatory Oversight:
  • • 1. Provide OU-level oversight for accreditation and regulatory compliance, including The Joint Commission (TJC), State, and Federal agencies.
    • 2. Remain current with accreditation standards, Conditions of Participation, and regulatory requirements; interpret and translate standards into operational expectations.
    • 3. Serve as the primary OU resource for accreditation and regulatory guidance across departments and service lines.
• Survey Readiness:
  • • 1. Plan, lead, and conduct routine tracers and readiness assessments
    • 2. Provide real-time coaching and education.
    • 3. Identify gaps, risks, and trends; develop actionable recommendations and monitor corrective action plans.
    • 4. Support preparation for announced and unannounced accreditation, licensure, and validation surveys. Education,
• Training & Consultation:
  • • 1. Develop and deliver education and training related to accreditation standards, regulatory requirements, and continuous survey readiness
    • 2. Educate leaders and frontline staff on standards interpretation, tracer methodology, and survey expectations.
    • 3. Serve as a consultant to departments on regulatory compliance, process redesign, and risk mitigation.
• Performance Improvement & Collaboration:
  • • 1. Collaborates with leadership to recommend sustainable processes and system improvements to maintain quality metrics and/or accreditation-related objectives that support high reliability and ongoing readiness.
    • 2. Facilitate interdisciplinary workgroups and committees focused on accreditation readiness and regulatory compliance.
• Reporting & Documentation:
  • • 1. Track, trend, and report accreditation readiness activities, tracer findings, and corrective action status.
    • 2. Support regulatory documentation, policy alignment, and evidence management to ensure survey readiness
• Other Duties as Assigned.

Travel: Less than 10% of the time may be required.

Work Type: On-site employee

Minimum Required Qualifications Education:

• Bachelor's degree (BA/BS) in a health-related field required.
• Experience: Five (5) years of experience in a clinical healthcare environment.
• Experience in clinical operations and/or performance improvement, patient safety, risk management, or quality management.

Skills, Abilities & Knowledge:

• Knowledge of Quality Improvement methodologies, group facilitation, project management, and healthcare regulatory and event reporting requirements.

Preferred Qualifications Experience:

• Previous accreditation and/or regulatory readiness experience preferred.
• Licensure: Licensure as a Registered Nurse in the state of Georgia strongly preferred.

Additional Details

Emory is an equal opportunity employer, and qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.

Emory Healthcare is committed to providing reasonable accommodations to qualified individuals with disabilities upon request. Please note that one week's advance notice is preferred.