Quality, Compliance & Accreditation Lead

Delphi Technologies; Hamilton Township (NJ); On-site; USD 75,000 - 89,000; Full time

Job summary

Catholic Charities, Diocese of Trenton is seeking a Quality, Compliance and Accreditation Manager to support quality improvement, compliance, accreditation, and risk management activities. The role requires collaboration with leadership and program staff to promote process improvement, safety, and regulatory readiness across the organization.

Responsibilities include audits, data analysis, policy development, and liaison with licensing bodies.

Qualifications

• Bachelor’s degree in healthcare administration, Nursing, Social Work, Psychology, Public Health or related field.
• Master's degree preferred.

Responsibilities

• Coordinate quality improvement, compliance, accreditation, and risk management activities.
• Conduct scheduled and unannounced case record audits for compliance with Joint Commission, state licensing, payer, and organizational standards.
• Conduct facility and environmental compliance rounds assessing Environment of Care, Infection Control, Medication Management, Life Safety, and National Patient Safety Goals.
• Coordinate Joint Commission survey readiness, mock surveys, tracers, and evidence collection with leadership and program staff.
• Collect, analyze, trend, and report quality and compliance data.
• Serve as a liaison for licensing inspections, payer audits, and other regulatory reviews as assigned.
• Coordinate survey logistics, documentation, and responses, and escort surveyors during site visits.
• Participate in and/or chair Quality Improvement, Safety, Infection Control, and other assigned committees.
• Prepare committee agendas, minutes, reports, and monitor follow-up activities.
• Coordinate development, review, revision, implementation, and communication of policies and procedures.
• Serve as Quality Improvement representative for assigned programs.
• Develop audit tools, dashboards, scorecards, and monitoring systems.
• Assist with Plans of Correction and performance improvement initiatives across the organization.
• Monitor completion and effectiveness of corrective actions.
• Review incidents, sentinel events, and risk data; investigate and complete Root Cause Analyses.
• Provide education regarding regulatory and accreditation standards and documentation requirements.
• Monitor regulatory and accreditation changes and communicate updates.
• Collaborate with program staff, operational and clinical leadership to improve quality and compliance.
• Perform other duties as assigned.

Skills

Analytical skills

Organizational skills

Communication skills

Project management

Education

Bachelor’s degree in healthcare administration, nursing, social work, psychology, public health or related field

Master’s degree preferred

Tools

Microsoft Office

Electronic Health Records (EHR)

Job description

Catholic Charities, Diocese of Trenton is seeking a Quality, Compliance and Accreditation Manager to support quality improvement, compliance, accreditation, and risk management activities. The role requires collaboration with leadership and program staff to promote process improvement, safety, and regulatory readiness across the organization.

Responsibilities include audits, data analysis, policy development, and liaison with licensing bodies.