Accreditation Services 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

Accreditation Services Director(Job Id 17784)

Location

US:DE:Dover

Post Date

10/7/2026

Category

Professional

Employment Type

Employee

Description

If you care about the opportunity to grow, to make a difference, to build a future and a life, then we just might have the career for you. Care to talk?

Bayhealth Medical Center is Central and Southern Delaware’s healthcare leader with hospitals in Dover and Milford, a s well as stand -alone Emergency Department in Smyrna and a hybrid E mergency Department and Urgent Care in Milton . We offer various practice settings throughout Kent and Sussex Counties. Bayhealth Medical Center Kent Campus is 90 minutes from Philadelphia, Washington, DC and Baltimore . Our Sussex Campus is 30 minutes to the Delaware beaches and relaxation in the sand!

Bayhealth Medical Center offers a competitive salary and comprehensive benefits package (for eligible positions) including:

• Generous Paid Time Off and Paid Holidays
• Matching 401(k)/403(b) Plans
• Excellent Health, Dental, and Vision
• Disability and Life Insurance options
• On Site Child Care
• Educational Reimbursement
• Health Care and Dependent Care Flex Spending Accounts
• Plus, an array of Voluntary Benefits to include Critical Care Coverage and more!

Location: Kent Campus Hospital, Dover Delaware

Status: Full Time 80 Hours Biweekly

Shift: Day/ Evening (Exempt)

SALARY RANGE:136,406.40 - 211,411.20 YEARLY

General Summary:

This position is responsible for Accreditation and Regulatory activity across the Bayhealth System. This responsibility requires providing oversight of a standard approach across all Bayhealth operating areas.

Serves as a subject matter expert on regulatory/accreditation and licensure standards and all external expectations associated with compliance in this area. Provides oversight and ongoing internal consultation for all external survey-related activities to ensure continual compliance with requirements and ongoing readiness for survey activity. Works closely with organizational leaders to identify and monitor compliance in key critical areas and elevate improvement opportunities on a timely basis. Provides oversight into the effective use of external consultants as necessary and all processes focused on improvement in this area, such as the use of mock surveys and focused tracer activities. Provides vision and structure to the internal tracer activity program. Provides a standard approach across Bayhealth for education, survey preparation, survey follow-up/corrective action plans, and ongoing GAP analyses of regulatory/accreditation requirements based on current hospital performance.

Provides oversight to the Bayhealth Policy and Procedure process and the Professional Sanction Check Process. Position is responsible for all budgeting, hiring, and performance management of staff in the Accreditation Services Area.

Responsibilities:

• 1. Position provides oversight into the development and implementation of standard processes across all Bayhealth entities which support successful compliance with all external accreditation and regulatory requirements of the Joint Commission (TJC), Delaware Department of Health and Social Services (DDHSS), and the Center for Medicare and Medicaid Services (CMS).
• 2. Ensures that the following structures are in place to accommodate support of a standardized structure: defined committee meeting structure for accreditation/regulatory oversight; processes for GAP analyses and tracking of opportunities to resolution; uniform tracer program for compliance monitoring; processes for issue prioritization and identification/escalation of critical issues; facilitation of ongoing educational program for staff, medical staff and leaders; creation/dissemination of compliance monitoring reports; and identification of critical standards/regulations for continual monitoring.
• 3. Serves as Chief Liaison for Bayhealth to all entities associated with TJC, DDHSS and CMS. Serves as the first point of contact for organization-wide activity.
• 4. Provides ongoing expertise and support to all Bayhealth Leaders and Departments associated with accreditation/regulatory compliance, which includes departmental/unit-based education, compliance monitoring, policy and procedure review, external resource coordination as necessary, and support with interpretation of external requirements.
• 5. Coordinates the use of all external resources, including consultants and mock survey activities. Provides oversight to the post-activity follow-up and closure for identified opportunities.
• 6. Prepares and submits all required external reporting including: TJC annual applications, all pre-survey requested documentation, completion of corrective action plans for DDHSS, TJC, and CMS.
• 7. Maintains current professional knowledge in all requirements associated with TJC, DDHSS, and CMS and educates Bayhealth constituencies on the same. Participates in continuing education relevant to all associated activities.
• 8. Provides oversight of the Bayhealth Policy and Procedure Review and Approval Process. Ensuring compliance with external accreditation/regulatory requirements.
• 9. Provides oversight of the Professional Sanction Check and Due Diligence Process.
• 10. Responsible for the Leadership oversight of Accreditation Services, which includes policy and procedure maintenance, recruitment and hiring of staff, negotiation of applicable contracts, ongoing performance management of staff, management of external support/consultants, and budgetary management.
• 11. All other duties assigned within the scope and range of job responsibilities.

Required Education, Credential(s) and Experience:

• Education:
• Bachelors Degree in Nursing (BSN)
• Preferred: Masters Degree in health related field
  ;
  
• Credential(s):
• Registered Nurse
  Preferred: Certified Professional in Healthcare Quality
  ;
  
• Experience:
• Required: Five (5) years successfully leading Accreditation and Regulatory processes associated with TJC, CMS, State Hospital Licensure, and other Accreditation Organizations. Preferred: Greater than five (5) years in accreditation/regulatory.

To view a full list of all open position at Bayhealth, please visit: