Senior Director of Accreditation

Cleveland Clinic; Cleveland (OH); On-site; USD 112,000 - 171,000; Full time

Job summary

Cleveland Clinic’s Main Campus is seeking a Senior Director of Accreditation to lead strategy, implementation, and oversight of accreditation and regulatory readiness across Ohio and Florida. You will work with enterprise leaders to ensure compliance with TJC, CMS, and ODH, serving as a trusted advisor and change agent.

This role leads a team of about 33 caregivers, drives continuous improvement, and supports acquisition due diligence and international initiatives.

Qualifications

• Bachelor’s degree in a health-related field required.
• Health Accreditation certifications (HACP or CJCP) required within 1 year if not held.
• 10+ years health care experience with 5+ years in accreditation and 5+ years leadership.
• Experience with CMS and state licensing agencies.
• Strong interpretive, communication, and leadership abilities.

Responsibilities

• Lead strategy, implementation, and oversight of accreditation and regulatory readiness.
• Coordinate surveys with TJC, CMS, and ODH enterprise-wide.
• Partner with clinical, operational, and executive leaders to drive quality and safety.
• Direct on-site survey activities and post-survey action plans.
• Support due diligence for acquisitions and international initiatives.

Skills

Leadership

Communication

Strategic planning

Regulatory knowledge

Project management

Team development

Education

Bachelor's degree in health-related field

Job description

Join Cleveland Clinic’s Main Campus where research and surgery are advanced, technology is leading-edge, patient care is world class and caregivers are family. Here, you will work alongside a passionate and dedicated team, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.

As Senior Director of Accreditation, you will lead the strategy, implementation, and oversight of accreditation and regulatory readiness across Cleveland Clinic’s enterprise hospitals in Ohio and Florida. In collaboration with the Senior Director of Regulatory Affairs, you will oversee accreditation activities before, during, and after surveys conducted by agencies including The Joint Commission (TJC), Centers for Medicare and Medicaid Services (CMS), and Ohio Department of Health (ODH). You will serve as an enterprise resource and consultant, lead on-site survey activities, and build strong partnerships with clinical, operational, and executive leaders to advance a proactive, consistent approach to regulatory readiness, safety, quality, and continuous improvement. You will also support acquisition due diligence and onboarding activities and provide regulatory and accreditation guidance for Cleveland Clinic’s international initiatives.

This is an exciting opportunity to lead a talented team of approximately 33 caregivers and shape the future of accreditation and regulatory readiness across the organization. You will have a pivotal role in strengthening the enterprise approach, developing a cohesive, high-performing team, and embedding a culture of continuous improvement into everyday operations. The ideal candidate will bring strategic vision, exceptional relationship-building skills, and a passion for developing people and leading meaningful organizational change.

A caregiver in this role works Monday through Friday from 8:00 a.m. – 5:00 p.m., with on-call responsibilities and 5%–10% travel requirements.

A caregiver who excels in this role will:

• Effectively direct activities related to TJC including application submission, survey planning and logistics, post-survey Evidence of Standards Compliance (ESC) and annual intracycle monitoring.
• Direct continuous readiness activities including Continuous Readiness Rounds, Tracer Teams, Mock Surveys, Intranet Accreditation site content, and educational materials and activities.
• Leas and coordinate regulatory on-site surveys, including but not limited to TJC, ODH and CMS.
• Responsible for effective post survey action plans and formal responses to accrediting and regulatory agencies.
• Maintain current knowledge of accreditation and compliance issues affecting healthcare.
• Stay abreast of changes in TJC standards, JCI (Joint Commission International) Standards, Ohio Administrative Code and Ohio Regulatory Code, CMS Conditions for Coverage and Conditions of Participation requirements and standards.
• Communicate standard changes to executive leadership and others in the organization who need to know.
• Collaborate with Enterprise Quality Departments and organization Institutes to ensure Cleveland Clinic is compliant with accreditation standards and regulatory requirements.
• Other duties as assigned.

Minimum qualifications for the ideal future caregiver include:

• Bachelor’s Degree in health-related field
• Certifications required: Healthcare Accreditation Certified Professional (HACP) or Certified Joint Commission Professional (CJCP) (If applicant does not have one of these certifications, they will need to achieve certification within one year)
• Ten years of health care experience in a clinical discipline including at least five years of accreditation experience and five years of leadership/management experience
• Specific experience related to accreditation and regulatory bodies, such as CMS and state licensing agencies
• In-depth knowledge of accrediting and regulatory standards
• Demonstrated ability to interpret standards, serve as a subject matter expert and communicate information to all levels in the organization
• Ability to manage employees and prioritize and manage multiple tasks simultaneously
• Demonstrated leadership skills
• Excellent communication skills

Preferred qualifications for the ideal future caregiver include:

• Master’s Degree
• Experience in International accreditation
• Demonstrated experience leading accreditation, regulatory, quality, or patient safety programs within a complex healthcare organization
• Experience leading and developing multidisciplinary teams, preferably across multiple hospitals or markets
• Demonstrated success leading organizational change, standardizing processes, and improving operational performance
• Strong executive presence and ability to influence and collaborate with senior clinical and operational leaders
• Experience applying continuous improvement methodologies to achieve sustainable results
• Ability to balance strategic leadership with operational execution

Physical Requirements

• Manual dexterity to operate office equipment
• Ability to lift and transport up to 15 pounds
• Requires extended periods of standing, walking and sitting.
• Normal or corrected vision and hearing to normal range.

Personal Protective Equipment

• Donning and doffing appropriate PPE when performing tracers or visiting patient care areas.

Pay Range

Minimum Annual Salary: $112,110.00

Maximum Annual Salary: $170,955.00

The pay range displayed on this job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set and education. The pay range displayed does not include any applicable pay practices (e.g., shift differentials, overtime, etc.). The pay range does not include the value of Cleveland Clinic’s benefits package (e.g., healthcare, dental and vision benefits, retirement savings account contributions, etc.).