Accreditation Services Program Manager

Bayhealth; Milford (DE); On-site; USD 94,000 - 145,000; Full time

Job summary

Bayhealth in Milford, DE seeks an Accreditation Services Program Manager to lead regulatory coordination with CMS, JCAHO, and state authorities. The role includes developing standardized processes, educating leadership, managing the tracer program, and coordinating on-site survey activities for Bayhealth’s Sussex Campus and related entities.

The position requires a Nursing Bachelor, RN licensure, and at least five years in acute care with two years in accreditation/regulatory work.

Qualifications

• Bachelor degree in Nursing required.
• Registered Nurse credential required.
• Minimum five years acute care nursing experience.
• Two years accreditation/regulatory experience preferred.

Responsibilities

• Oversee accreditation and regulatory processes across Bayhealth.
• Coordinate survey preparation and on-site activities.
• Lead the centralized tracer program administration and reporting.
• Develop and deliver education on accreditation standards for leaders, medical staff, and employees.
• Maintain survey documentation for Sussex Hospital Campus and affiliated entities.

Education

Bachelor Degree Nursing

Master Degree Nursing

Job description

Accreditation Services Program Manager(Job Id 17966)

Location: US:DE:Milford

Post Date: 11/3/2026

Category: Nursing/Nursing Support

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!

Status

Full Time 80 Hours Biweekly

Shift

Days (Exempt)

SALARY RANGE

93,724.80 - 145,288.00 YEARLY

General Summary

Under the direction of and in collaboration with the Director of Accreditation Services, this position supports Bayhealth Medical Center and its associated entities in all activities related to the Joint Commission (TJC), Delaware Department of Health and Social Services (DDHSS) and the Center for Medicare and Medicaid Services (CMS). Serves as a resource and expert on regulatory/accreditation and licensure standards for Bayhealth system. Provides oversight and ongoing internal consultation for all Survey Readiness activities. Works closely with organizational leaders to identify and monitor compliance in critical areas and to escape improvement opportunities to leadership in a timely manner. Assists across the organization in the production of monitoring reports and use of centralized tracer tool/software, as necessary. Services as the administrator of the centralized tracer tool. Serves as the lead regulatory expert for Sussex Hospital and associated entities for all coordination and external entity visits.

Under the direction of and in collaboration with the Director of Accreditation Services, this individual develops and delivers education to leaders, medical staff, and employees on accreditation and regulatory issues. Provides leadership to a standardized approach to systems developed for survey preparation, on-site survey activity, corrective action creation , and follow-up. Leads all on-site inspections by the Center for Medicare/Medicaid Services (CMS) and Delaware Department of Health and Social Services for patient complaints and other associated activities. Acts as primary liaison with accrediting, licensing, and certifying organizations, including the Joint Commission, Delaware Department of Health and Social Services, and Centers for Medicare/Medicaid Services for the Sussex Campus.

Responsibilities

1. Under the direction of and in collaboration with the Director of Accreditation Services, Position provides oversight to 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. Supports the Director of Accreditation Services and organizational leaders by facilitating the following accreditation/regulatory standardized structure/strategies: : 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 on-going educational program for staff, medical staff and leaders; creation/dissemination of compliance monitoring reports; and identification of critical standards/regulations for continual monitoring
3. Develops and provides education to leaders, medical staff, and employees on standards and processes related to the survey and external complaint processes, as well as The Joint Commission, CMS, Delaware Department of Health and Social Services, and other regulatory bodies as applicable to the hospital.
4. Serves as the Bayhealth system administrator of the organizational system tracer program. In this activity, supports the development and implementation of all tracers requested for on-going monitoring and readiness and provides training to the use of the system and report writing capabilities.
5. In the absence of the Director of Accreditation Services, acts as a liaison with accrediting, licensing, and certifying organizations, including the Joint Commission, Delaware Department of Health and Social Services, and Centers for Medicare/Medicaid Services.
6. Coordinates survey preparation, on-site survey activity, and survey follow-up, including coordination of all improvement actions taken because of deficiencies/recommendations received during surveys/inspections primarily for Sussex Hospital and serves as the Director’s delegee in his/her absence for the rest of Bayhealth.
7. Supports Departments/Patient Care – Units in interpretation of applicable accreditation and regulatory requirements and GAP analysis to current operational activities. Supports the development of action plans and associated monitoring to come into compliance where necessary.
8. Provides support to the Director of Accreditation Services in the development and review of policies and procedures related to accreditation and regulatory processes and requirements. Reviews newly developed policies/procedures from Departments/Divisions to ensure compliance with accreditation/regulatory requirements.
9. Performs Bayhealth-wide Departmental/Unit-based tracers to support oversight of focused tracers as the need arises and to perform just in time education as necessary and required.
10. Maintains confidentiality of all information as well as the release of any information.
11. Participates in continuing education relevant to Joint Commission standards, Delaware Department of Health and Social Services, and CMS regulations. Stays current in the field of accreditation/regulatory coordination through conference attendance, distance learning and networking at a minimum.
12. Primary responsibility for survey documentation maintenance for the Sussex Hospital Campus and affiliated entities.
13. All other duties assigned within the scope and range of job responsibilities.

Required Education, Credential(s) and Experience

• Education:
• Bachelor DegreeNursing
• Credential(s):
• Registered Nurse
• Experience: Required: Five (5) years of experience in an acute care nursing environment. Two (2) years of accreditation/regulatory experience.

Preferred: Five (5) years in accreditation/regulatory.

Preferred Education, Credential(s) and Experience

• Education:
• Master Degree Nursing
• Credential(s):
• Certified Professional in Healthcare Quality

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