ZipRecruiter

Log In

1

Hospital Accreditation Manager Jobs (NOW HIRING)

Kaiser Permanente

Mgr Imaging

Silverdale, WA · On-site

Work experience demonstrating knowledge of hospital regulatory requirements, hospital accreditation and imaging accreditations, managed care and health care delivery systems. * Demonstrated ability ...

next page

Showing results 1-20

All JobsEducation JobsHigher Education JobsFaculty Administrator JobsHospital Accreditation Manager Jobs

Hospital Accreditation Manager information

What does a hospital accreditation manager do?

A Hospital Accreditation Manager oversees a healthcare facility’s compliance with accreditation standards set by regulatory bodies such as The Joint Commission or other accrediting organizations. They coordinate preparation for surveys, conduct internal audits, and educate staff on best practices to ensure high-quality patient care. Their role is crucial in maintaining accreditation status, which impacts hospital reputation, funding, and ability to operate. They also stay updated on changing regulations and implement necessary policy updates throughout the hospital.

What are some common challenges faced by hospital accreditation managers during the accreditation process?

Hospital Accreditation Managers often face the challenge of aligning diverse departments with complex regulatory standards and ensuring timely documentation. Coordinating multidisciplinary teams to address compliance gaps and prepare for surveys requires strong organizational and communication skills. Additionally, adapting to evolving accreditation standards and maintaining staff engagement throughout the process can be demanding. However, these challenges also present opportunities to foster a culture of continuous improvement within the hospital.

What are the key skills and qualifications needed to thrive as a hospital accreditation manager, and why are they important?

To thrive as a Hospital Accreditation Manager, you need a strong background in healthcare administration, regulatory compliance, and quality management, often supported by a bachelor's or master's degree in a related field. Familiarity with accreditation standards (such as Joint Commission or DNV), quality improvement tools, and data management systems is essential. Exceptional organizational, analytical, and communication skills help in leading audits, training staff, and ensuring ongoing compliance. These competencies are crucial for maintaining hospital accreditation status, improving patient safety, and supporting institutional excellence.

What is the difference between Hospital Accreditation Manager vs Hospital Quality Coordinator?

AspectHospital Accreditation ManagerHospital Quality Coordinator
Required CredentialsBachelor's degree, certifications in healthcare quality or accreditationBachelor's degree, certifications in healthcare quality or patient safety
Work EnvironmentAdministrative offices, hospital management teamsClinical departments, quality improvement teams
Employer & Industry UsageHospitals, healthcare organizations focusing on accreditationHospitals, clinics, healthcare facilities focusing on quality improvement
Common Search & ComparisonYesYes

The Hospital Accreditation Manager primarily oversees hospital compliance with accreditation standards, managing documentation and liaising with accrediting bodies. The Hospital Quality Coordinator focuses on implementing quality improvement initiatives and monitoring patient safety. While both roles require similar credentials and work within healthcare settings, the Accreditation Manager has a broader administrative focus, whereas the Quality Coordinator emphasizes clinical quality projects.

What are popular job titles related to Hospital Accreditation Manager jobs?

For Hospital Accreditation Manager jobs, the most frequently searched job titles are:

Infographic showing various Hospital Accreditation Manager job openings in the United States as of September 2026, with employment types broken down into 86% Full Time, 13% Part Time, and 1% Contract. Highlights an 86% Physical, 2% Hybrid, and 12% Remote job distribution.

Manager, Accreditation & Regulatory Compliance (Ukiah)

Ukiah, CA • On-site

Adventist Health
Non-Profits • 10K+ employees
Learn more about Adventist Healthexternal

Other

Re-posted 29 days ago

Adventist Health rating

7.7

Company rating: 7.7 out of 10

Based on 247 frontline employees who took The Breakroom Quiz

Job description


Adventist Health Ukiah Valley has been deeply connected to the community we serve since 1956. We are comprised of a 50-bed acute care medical center, level IV trauma center, level II intensive care nursery services, extensive physical rehabilitation program, outpatient surgery and diagnostic center and advanced wound care center. Ukiah is a unique small town that charms you with its rich character, arts, vineyards and natural surroundings. Ukiah beckons you to explore all that the valley has to offer amidst our 300 days of sunshine each year. We are also conveniently located just two hours north of San Francisco and 45 minutes from the Pacific Coast.
Job Summary:
Directs day-to-day regulatory readiness activities, including internal audits, mock surveys, tracer programs, and regulatory education across clinical and operational departments at assigned hospitals/markets. Implements system strategies and supports continuous survey readiness through operational execution. Leads site/network accreditation, regulatory compliance, and licensing operations, ensuring continuous readiness and alignment with Centers for Medicare & Medicaid Services (CMS), The Joint Commission, and state requirements. Leads corrective action planning, staff training, and policy implementation at facility level. Manages all surveys and regulatory compliance with various governmental agencies, including the Joint Commission. Manages improvement processes and programs related to all accreditation preparation and licensing, ensuring sustained compliance with submitted plans of correction. Works closely with nursing, medical staff and other disciplines as part of an organizational team to provide focus and education on accreditation, regulatory and licensing issues. Manages the activities of various levels of assigned personnel utilizing both professional and supervisory discretion and independent judgment. Maintains a dotted line reporting structure to the system director of accreditation, regulatory, and licensing. Oversees accreditation and regulatory compliance activities affecting all clinical and non-clinical departments, ensuring regulatory requirements are integrated into operational workflows, policies, and performance improvement initiatives.
Job Requirements:
Education and Work Experience:
  • Bachelor's Degree or equivalent combination of education/related experience: Required
  • Master's Degree: Preferred
  • Five years' healthcare or related experience: Preferred
  • Three years' in accreditation, regulatory compliance or process improvements: Preferred
  • Two years' leadership experience: Preferred
Licenses/Certifications:
  • Healthcare Accreditation Certificated Professional (HACP) or Certified Professional in Healthcare Quality (CPHQ) certification: Required within 2 years of hire date
Essential Functions:
  • Partners with system, network, and site leadership to align regulatory compliance programs with organizational strategy, quality initiatives, patient safety priorities, and risk reduction goals. Partners with clinical and non-clinical staff to develop, implement, monitor and improve structures required to achieve high quality, safe, cost-effective health care. Assists managers and leaders to mobilize various teams throughout the organization to ensure continuous accreditation standards compliance. Coordinates contract renewal and oversight activities associated with regulatory compliance monitoring system.
  • Provides leadership and expertise in the pursuit and attainment of organizational goals related to accreditation, licensing and regulatory compliance. Manages a team of professionals who collectively safeguard facility licensing status, maintain accreditations/certifications, and assure compliance with a vast range of healthcare regulations.
  • Conducts annual State regulatory compliance assessment. Develops and maintains any action plan and response to citations for any regulatory agency. Collects data and prepares graphic presentation, and compiles reports to demonstrate compliance. Reviews, interprets and assists hospital departments, leadership and Medical Staff in the implementation of Federal, State and Joint Commission standards and regulations.
  • Designs and implement systems to ensure a state of continual regulatory, licensure and accreditation compliance. Supports the accreditation preparation process for the organization by managing logistics, conducting mock surveys and maintaining organization's communication regarding changes and updates for regulatory compliance. Maintains and controls all regulatory, licensure and accreditation documents. Monitors Joint Commission standards compliance. Conducts periodic internal reviews and/or audits to ensure compliance procedures are followed. Identifies compliance issues that require follow-up or investigation. Manages the internal investigations of compliance issues. Reviews operational risks and develops risk management strategies
  • Prepares and submits reports following the review of unusual occurrences and adverse events. Alerts appropriate regulatory bodies as required in partnership with network director. Reviews unusual occurrences and adverse events, ensuring that immediate corrective actions are implemented for all reportable events to safeguard patient safety and regulatory compliance. Maintains accurate documentation and reporting systems to support timely submission of required reports and regulatory filings, in alignment with organizational and regulatory standards. Participates in root cause analysis, apparent cause analysis as needed. Collaborates with Risk Management, Quality, Medical staff and other hospital departments as needed in matters related to regulatory compliance, policy planning, and implementation.
  • Performs other job-related duties as assigned.

Organizational Requirements:
Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.
Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.
About Us
Adventist Health is a faith-based, nonprofit, integrated health system serving more than 100 communities on the West Coast and Hawaii with over 440 sites of care, including 27 acute care facilities. Founded on Adventist heritage and values, Adventist Health provides care in hospitals, clinics, home care, and hospice agencies in both rural and urban communities. Our compassionate and talented team of more than 38,000 includes employees, physicians, Medical Staff, and volunteers driven in pursuit of one mission: living God's love by inspiring health, wholeness and hope.

What Adventist Health employees say

Pay

Benefits

Hours and flexibility

Workplace

Get the full story on Breakroom

Apply