Program Manager Accreditation

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

Program Manager Accreditation

Location

Cleveland

Facility

Cleveland Clinic Main Campus

Department

Office Of Accreditation Main Campus-Clinical and Operational Improvement

Job Code

T30059

Shift

Days

Schedule

7:00am-4:00am

Job Summary

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 Program Manager, Accreditation, you will coordinate hospital accreditation activities and ensure continuous survey readiness across the hospital, affiliated organizations, and off-site facilities. In this role, you will collaborate with senior leadership to identify and implement targeted interventions that promote a culture of continuous patient readiness.

 

A caregiver in this role works Monday through Friday from 7:00 a.m. -- 4:00 p.m.

 

A caregiver who excels in this role will:

• Develop, manage, and maintain programs designed to ensure Cleveland Clinic compliance with accreditation and regulatory standards, including those established by The Joint Commission (TJC), the Ohio Department of Health (ODH), and the Centers for Medicare & Medicaid Services (CMS).
• Serve as a primary resource for staff, facilitating the effective operation of accreditation and regulatory programs.
• Provide consultation to departments and institutes on all aspects of TJC and other regulatory agency requirements.
• Educate and disseminate accurate information to clinical and nonclinical departments regarding certifications, accreditation requirements, and regulatory standard interpretations.
• Participate in preparation for and support onsite accreditation and regulatory survey activities.
• Collaborate with departments throughout the Quality and Patient Safety Institute to promote safe, high-quality patient care.
• Develop, manage, and oversee various projects related to accreditation and regulatory compliance.
• Conduct rounds throughout the organization to identify vulnerabilities, assess compliance with applicable standards, and engage staff in opportunities for improvement.
• Influence organizational change by working with departments and institutes to implement practices that align with CMS, TJC, and other regulatory requirements.
• Work directly with surveyors from accreditation and regulatory agencies during onsite reviews, including unannounced surveys.
• Review survey findings and accreditation correspondence, develop plans of correction, submit them for organizational approval, and monitor implementation to ensure sustained compliance.
• Develop proficiency in applicable accreditation standards, regulatory requirements, and standard operating procedures (SOPs) through education, self-study, and ongoing experience.
• Support a variety of accreditation programs and requirements across the organization, adapting to the needs of different departments and institutes.
• Participate in committees and meetings related to accreditation, regulatory compliance, and patient safety.
• Perform other duties as assigned.

 

Minimum qualifications for the ideal future caregiver include:

• Bachelor's degree in Nursing, Healthcare Administration, Business, Engineering or related field and five years of related experience with Quality Management, Risk Management/Patient Safety and Performance Improvement program or related healthcare experience
• OR Associate’s degree and seven years of experience
• OR Master’s degree and four years of experience
• Demonstrated knowledge in principles of risk management, quality and performance improvement methods
• Working knowledge of accreditation and regulatory standards
• Healthcare Accreditation Certification Program (HACP) or Certified Joint Commission Professional (CJCP) certifications will be required within two years of hire

 

Preferred qualifications for the ideal future caregiver include:  

• Master’s degree
• Healthcare background

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.

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment as required for procedures.

                       

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster. 

Cleveland Clinic is pleased to be an equal employment opportunity employer.