Accreditation Manager

Emory Healthcare; Decatur (AL); On-site; USD 90,000 - 115,000; Full time

Benefits offered by this job

Health benefits from day 1

Student loan assistance

Mentorship programs

Job summary

Emory Healthcare seeks an Accreditation Manager to provide OU-level direction, oversight, and support for accreditation compliance. The role leads readiness activities, partners with clinical and executive leaders, and drives standardization and continuous improvement aligned with Always Patient Ready.

Responsibilities include tracer readiness, coaching, and guiding departments on regulatory expectations. Travel is < 10% with on-site work; RN licensure in GA preferred.

Qualifications

• Bachelor's degree in a health-related field required.
• 5 years of experience in a clinical healthcare environment.
• Experience in clinical operations and/or performance improvement, patient safety, risk management, or quality management.
• Licensure as a Registered Nurse in Georgia strongly preferred.
• Knowledge of quality improvement methodologies, group facilitation, project management, and healthcare regulatory and event reporting requirements.

Responsibilities

• Accreditation & Regulatory Oversight: provide OU-level oversight for accreditation and regulatory compliance with The Joint Commission, state, and federal agencies.
• Survey readiness: plan, lead, and conduct routine tracers and readiness assessments; provide real-time coaching.
• Education, Training & Consultation: develop and deliver education and training on accreditation standards and regulatory requirements.
• Performance Improvement & Collaboration: collaborate with leadership to recommend sustainable processes and system improvements; facilitate interdisciplinary workgroups.
• Reporting & Documentation: track, trend, and report readiness activities, tracer findings, and corrective action status; support regulatory documentation and policy alignment.

Skills

Quality Improvement

Group facilitation

Project management

Healthcare regulatory reporting

Education

Bachelor's degree (BA/BS) in a health-related field

Job description

Overview

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

Job Summary: 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. PHYSICAL REQUIREMENTS (Medium): 20-50 lbs; 0-33% of the work day (occasionally); 11-25 lbs, 34-66% of the workday (frequently); 01-10 lbs, 67-100% of the workday (constantly); Lifting 50 lbs max; Carrying of objects up to 25 lbs; Occasional to frequent standing & walking, Occasional sitting, Close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks. ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste Chemicals/gases/fumes/vapors Communicable diseases Electrical shock, Floor Surfaces, Hot/Cold Temperatures, Indoor/Outdoor conditions, Latex, Lighting, Patient care/handling injuries, Radiation, Shift work, Travel may be required. Use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.

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 contact Emory Healthcare's Human Resources at [e-mail]. Please note that one week's advance notice is preferred.