Director-Accreditation

Position Overview

Mayo Clinic seeks an accomplished visionary leader to serve as the Director of Accreditation the enterprise executive responsible for systemwide oversight of accreditation across hospitals critical access hospitals ambulatory and home care settings behavioral health diseasespecific certifications and other programs as assigned. The Director will ensure sustained readiness and exemplary performance against federal and accrediting body requirements including CMS HHS State Departments of Health The Joint Commission (TJC) and DNV Healthcaretranslating complex regulations into clear reliable practices that create safer systems for patients and elevate care.

Primary Accountabilities

• Enterprise Strategy & Governance:Set the vision and strategic direction for Mayo Clinics Accreditation Program; lead planning implementation and evaluation of accreditation and regulatory activities across all sites to maintain accreditation status and CMS certification.
• Continuous Readiness & Risk Mitigation:Advance proactive tracer methods and readiness practices that integrate survey tracer and operational data to identify risk early reduce harm and accelerate improvement.
• Survey Excellence:Direct endtoend survey management including onsite regulatory surveys and investigations by accrediting state and federal agencies; oversee corrective actions and ensure sustained outcomes postsurvey.
• Modernization & Automation:Champion modernization of accreditation tools and processesleveraging data automation and AIenabled regulatory monitoringto reduce burden increase reliability and measurably enhance patient safety.
• Education & Communication:Lead enterprise interpretation of standards and communicate requirements in accessible actionable ways; equip leaders and frontline teams with resources that embed accreditation into daily clinical practice.
• External Representation:Serve as Mayo Clinics liaison to accrediting licensing and regulatory bodies; provide leadership and advocacy through participation in accrediting body committees and national policy forums.
• People & Financial Stewardship:Manage accreditation staff across the enterprise and provide financial oversight for the accreditation budget fostering a highperforming missiondriven team.

Qualifications

• Masters degree in business health care administration or related field; minimum 10 yearsof progressive healthcare management or regulatory compliance experience.
• Clinical degree (e.g. RN PT RT) or advanced certifications in compliance/accreditation preferred; CPHQ CPHRM or HACPare valued.
• Demonstrated excellence in written and verbal communication; proven change leadership strategic planning and operational execution; high integrity executive presence and creativity.
• Expertise in conflict management; systems thinking; team dynamics; outcomes management; continuous improvement methodologies; and risk assessment/management.
• Significant experience with Joint Commission standards CMS Conditions of Participation and external regulatory requirements.

Leadership Attributes

The successful candidate views accreditation as a catalyst for transformation and measurable improvement in patient outcomes. This leader harmonizes scientific rigor with practical executionmaking standards intuitive embedding reliability into daily workflow and ensuring that continuous readiness translates into safer care for patients and teams alike.

The Value of this Role

Mayo Clinics Accreditation Program is recognized as bestinclass with standardized proactive readiness strategies tools and resources that enable clinicians to focus on delivering safe exceptional care while maintaining an unwavering compliant posture. The Director will elevate this foundationlinking standards to safety modernization and enterprise value.

Masters degree in business health care administration or related field and 10 years progressive healthcare management or regulatory compliance experience required. Juris Doctor degree or advanced certifications in compliance or accreditation preferred. Excellent written and verbal communication skills. Change management leadership strategic planning and operational skills required. High level of professional integrity executive presence and creativity required. Expertise at dealing with difficult situations and conflict management. Demonstrated expertise and skill in systems thinking and team dynamics outcomes management quality/continuous improvement philosophies and methodologies and risk assessment and management. Must have significant experience and understanding of The Joint Commission Centers for Medicare and Medicaid Services Conditions of Participation and other external regulatory requirements. Ability to translate complex regulations into meaningful expectations that are readily communicated across the organization at all levels; supports flexible solutions to ensure regulatory compliance and balance practice innovation. Manages resources effectively and plans for resources needed to support prioritized programs. Licensure/Certification Required: CPHQ CPHRM or HACP preferred.