Senior Director of Accreditation

ccf; Oklahoma; On-site; USD 150,000 - 210,000; Full time

Job summary

Cleveland Clinic Health System is seeking a Senior Director of Accreditation to lead strategy, implementation, and oversight of accreditation and regulatory readiness across enterprise hospitals in Ohio and Florida.

You will collaborate with senior leaders and oversee surveys from TJC, CMS, and ODH, serving as an enterprise resource and managing on-site surveys while shaping a proactive culture of safety, quality, and continuous improvement.

Qualifications

• Bachelor's degree in a health-related field required.
• Ten years of healthcare experience with five years in accreditation and five years in leadership.
• Experience with CMS, TJC, and state licensing standards.
• Strong interpretation of standards and organization-wide communication.

Responsibilities

• Lead strategy and oversight of accreditation readiness for Ohio and Florida hospitals.
• Collaborate with regulatory affairs to guide surveys and post-survey actions.
• Direct on-site survey activities and enterprise-wide readiness initiatives.
• Partner with clinical, operational, and executive leaders to embed continuous improvement.
• Support due diligence for acquisitions and international initiatives.

Skills

Leadership

Strategic planning

Regulatory compliance

Communication

Project management

Education

Bachelor's Degree in health-related field

Job description

At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

We all have the power to help, heal and change lives - beginning with our own. That's the power of the Cleveland Clinic Health System team, and The Power of Every One.

Job Title

Senior Director of Accreditation

Location

Cleveland

Facility

Cleveland Clinic Main Campus

Department

Office of Accreditation Corporate-Clinical and Operational Improvement

Job Code

T98654

Shift

Days

Schedule

8:00am-5:00pm

Job Summary

Job Details

Job Details

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 accreditat