Accreditation Manager Job Description

Accreditation Manager Job Description

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Accreditation manager provides strategic guidance and direction to the Comprehensive Cancer Committee to assure continued accreditation by the American College of Surgeons Commission on Cancer (ACoS CoC).

Accreditation Manager Duties & Responsibilities

To write an effective accreditation manager job description, begin by listing detailed duties, responsibilities and expectations. We have included accreditation manager job description templates that you can modify and use.

Sample responsibilities for this position include:

Collaborating with the Director of Quality and PI and identifying opportunities for improvement with the healthcare system
Evaluating requirements related to applicable accreditation and regulatory agencies and patient safety practices and outcomes
Participating in activities that prepare the organization for regulatory accreditation
Developing materials regarding regulatory compliance and patient safety and communicating information throughout the system
Providing consultative services for staff towards meeting standards of accreditation, performance improvement, organizational compliance, and patient safety initiatives and behavior
Managing implementation of PI program
Serves as point of contact, coordinating and collaborating with URAC and NCQA accreditation entities and business partners to ensure compliance with accreditation requirements
Serves as the SME for applicable accreditation standards
Develops tools that assist in determining exposure to accreditation risks and identifies opportunities to manage and mitigate those risks
Compiles information related to quality improvement and accreditation monitoring activities for internal use and external audits and maintains relevant records

Accreditation Manager Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Accreditation Manager

List any licenses or certifications required by the position: MOC, EPA, GOLD, PMP, CPHQ, ASQ, PMO, ISO27001, ISO, CHCP

Education for Accreditation Manager

Typically a job would require a certain level of education.

Employers hiring for the accreditation manager job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Master's Degree in Nursing, Education, Healthcare, Business, Management, Healthcare Administration, Health, Graduate, Health Care, Communication

Skills for Accreditation Manager

Desired skills for accreditation manager include:

IATF 16949
ISO 9001
National Committee for Quality Assurance Accreditation requirements
Quality activities
American College of Surgeons Commission on Cancer Standards and NQF Measures of Quality
Ability to achieve competency within 3 months of hire
Accreditation Council for Continuing Education and Training accreditation standards
Applicable regulatory requirements related to the healthcare staffing industry
Fax machines and other general office equipment
Federal regulations and policies related to vocational and continuing education

Desired experience for accreditation manager includes:

Monitors improvement action plans relating to accreditation compliance
Works with business management areas to develop metrics for monitoring program objectives and policies and procedures that support compliance with accreditation requirements
Responsible for the maintenance of the electronic distribution and housing of all related policies and procedures
Provides guidance and input to business unit audit functions to ensure ongoing accreditation and quality compliance
Makes recommendations to business unit partners for improvements or remediation to accreditation compliance programs
Monitors development and use of metrics for accreditation compliance and required quality improvement activities

Accreditation Manager Examples

1

Accreditation Manager Job Description

Job Description Example
Our innovative and growing company is searching for experienced candidates for the position of accreditation manager. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for accreditation manager
  • Collaborates with quality teams, utilization management teams, call centers and other departments on accreditation and quality improvement initiatives
  • Provides primary supports of quality committee activities
  • Assists with new hires, training, and coaching of unit associates
  • Participates in the budget process as needed
  • Leads and manages multiple, complex projects for a multi-faceted program associated with FEP Health Plan Accreditation
  • Ability to work through details while keeping a strategic focus
  • Individual contributor who works in a team environment comprised of project managers, program managers, and compliance specialists
  • Proactively supports and reports out to SVP and Sr
  • Ensures quality compliance with accrediting standards for all quality contractual obligations and accreditations with National Committee on Quality Assurance (NCQA), DMEPOS, URAC, and others
  • Supports external quality review organization audits, and applicable State government compliance audits relating to delegated oversight, and quality management functions
Qualifications for accreditation manager
  • Experience with formulating an accreditation budget
  • Leadership, project and resource management skills to effectively coordinate and motivate accreditation staff at the Plan level
  • Advanced analytical skills with the ability to analyze and interpret data and conduct complex analysis
  • Utilizes effective conflict management skills to manage competing interests and navigate difficult solutions including the ability to negotiate outcomes to ensure URAC compliance
  • Proficiency with the use of a variety of software applications (e.g., Microsoft Project, Word, Excel, and PowerPoint
  • Certified Professional in Healthcare Quality and/or Advanced certification by Academy for Healthcare Management
2

Accreditation Manager Job Description

Job Description Example
Our growing company is searching for experienced candidates for the position of accreditation manager. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for accreditation manager
  • Collaborates with various departments including quality, operations, mail service, call centers and other departments on improvement initiatives
  • Supports Senior Director and the Accreditations & Certifications team to plan, convene and facilitate various Quality Improvement (QI) committees and work groups, driving concise agendas to desired outcomes (based on accreditation requirements)
  • The Accreditation Manager oversees and manages all aspects of the police department accreditation program including the attainment and maintenance of CALEA accreditation
  • Acts as key contact for accreditation readiness committee(s) and working subgroup contributor
  • Ensures that the accreditation readiness program is in place by coordinating 'mock surveys' and collecting required supporting documentation, data and action plans
  • Maintains liaison relationship with peers and clinical affiliates by coordinating periodic (quarterly) joint sessions/meetings of key accreditation and quality and safety leaders
  • Conducts observation audit and chart review to support prioritized opportunities for improvement of projects related to annual operating plan and/or regulatory related topics using PDSA process
  • Age Specific / Cultural Competencies
  • Manages overall hospital regulatory accreditation program (CSR model)
  • Provides leadership guidance to programs applying for specific certification or centers of excellence
Qualifications for accreditation manager
  • 5 years’ experience in operations, quality assurance or management
  • Knowledge of clinical regulatory requirements (such as CMS and state regulatory agencies)
  • Knowledge of Managed Care, Health Systems, PBMs, Medical Groups, (minimum 2 years)
  • Experience with quality requirements related to accreditation, certification and compliance for programs such as NCQA, URAC, VIPPS, DMEPOS, State and Federal Regulations
  • ASQ CQA, CQE and / or CQM
  • Experience with CMS and State Regulatory Agencies
3

Accreditation Manager Job Description

Job Description Example
Our company is growing rapidly and is looking for an accreditation manager. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for accreditation manager
  • Collaborates with manager on budget preparation and management
  • Provide leadership on accreditation programs (URAC, NCQA, NABP, ACHC, and others) to ensure successful survey process from initiation to timely submissions, appropriate responses to requests for additional information and identify proactively opportunities to improve on future re-accreditation efforts
  • Provide Subject Matter Expert (SME) recommendation(s) on accreditation standards and skills to recognize the appropriate information is compliant
  • Acts as a key contributor for accreditation readiness committee(s)
  • Monitors mock audits activity to proactively identify opportunities for improvement for projects related to annual operating plan and/or regulatory related topics using PDSA (Plan, Do, Study, Act) process
  • Maintains liaison relationship with peers in functional departments by coordinating periodic (quarterly) joint sessions / meetings of key accreditation and quality and safety leaders
  • Maintains timelines continuously for all accreditation activities that can be communicated effectively to Senior Leadership to identify priorities and updates
  • Solves problems independently with the ability to prioritize in a fast-paced environment
  • Manages the process for identifying and resolving conflicts of interest for HMS GCE live activities
  • Collaborates with the Contracts and Finance Specialist if the activity is funded by commercial support to ensure that the appropriate information is communicated to the learners prior to the CME activity
Qualifications for accreditation manager
  • Certified Auditor (i.e., ASQ, CIA)
  • 5+ years of demonstrated field experience having managed (led) Accreditations, Certifications, and or Appraisals/Audits in related field
  • 3+ years of experience with accreditation and licensing survey preparation activity in a health care setting
  • Advanced skills with Microsoft applications which may include Outlook, Word, Excel, PowerPoint, May produce complex documents, perform analysis and maintain databases
  • Intermediate experience in Visio and Access
  • Bachelor's degree in clinical/healthcare management or related field
4

Accreditation Manager Job Description

Job Description Example
Our company is hiring for an accreditation manager. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for accreditation manager
  • Maintains accreditation databases including learning management system to ensure proper tracking of continuing education activities
  • Develops a closing process to ensure that appropriate documentation for compliance for all accreditation requirements is included in the electronic activity file
  • Develops and implements an annual activity file audit process and schedule to ensure activity compliance with ACCME, AMA, the Medical Specialty Boards, and HMS continuing medical education standards and regulations
  • Prepares for the HMS reaccreditation process through the ACCME and other accrediting bodies by providing information for and assistance with the Self-Study Report development and Performance-in-Practice activity files
  • Manages the process for collecting and preparing the data for the annual submission of the ACCME’s PARS Report
  • Implements strategies and action plans to incorporate the ABMS Maintenance of Certification® Program into HMS CME activities
  • In conjunction with the Accreditation team, develops program processes and procedures to meet the requirements for the appropriate Specialty Board
  • Maintains documentation in the activity files for all accrediting body requirements including the ACCME and ABMS Specialty Boards
  • Develops and maintains a list of content reviewers for appropriate Specialty Board to review educational content for eligibility for the appropriate Specialty Board
  • For appropriate Specialty Boards, tracks and monitors learner program completion and transmits all of the required information to ACCME or appropriate Specialty Board on behalf of the learners
Qualifications for accreditation manager
  • Prior experience in Rick Management
  • Bachelor’s degree or equivalent academic qualification
  • 6+ years relevant experience in a Quality Department
  • Ability to use analytical thinking to make critical decisions and solve business problems
  • Strong interpersonal skills highlighting communications excellence and professionalism
  • Effective team working abilities
5

Accreditation Manager Job Description

Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of accreditation manager. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for accreditation manager
  • Prepares required documentation for audits by the ACCME and Specialty Boards as necessary
  • Prepares reports, participates in meetings, works on projects, and provides support to the Director of Educational Development and Accreditation and the Senior Manager of Educational Development and Accreditation
  • Working as part of the Accreditation Program Office (APO), collect, prepare, analyze, and review qualitative and quantitative data submitted by multiple offices and individuals within HMS and the School’s affiliated hospitals
  • Propose and implement communication plans with various constituencies, including senior administrators and faculty at HMS and at affiliated hospitals
  • Staff committee meetings, which typically involves ensuring meetings are scheduled appropriately
  • Write, in coordination with faculty and/or staff leaders, subcommittee reports and submissions to the LCME data collection instrument (DCI)
  • Manage logistics for meetings with external groups, including consultant site visit(s), mock site visits, and the official LCME site visit in Spring 2019, in coordination with relevant staff assistants and/or office coordinators
  • Participate in relevant IPP office projects as assigned, such as those related to academic planning, school policy, or strategic initiatives
  • Implements a multidisciplinary approach to continued survey readiness that includes a steering committee and other committees as necessary
  • Leads the continued survey readiness program to include the development of detailed action plans, setting deadlines, assigning responsibilities and monitoring progress
Qualifications for accreditation manager
  • Self-motivated, detail oriented, with high-regard for meeting deadlines
  • Strong computer skills (high proficiency in Microsoft Excel)
  • Bachelor’s degree in a healthcare related field and graduation from an accredited school of nursing
  • Thinks Strategically - Understands the internal/external environment impacting future business direction
  • Confident in use of typical office IT systems
  • Bachelor’s degree or equivalent experience in nursing, public health, health administration, or health related field required

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