Director of Accreditation and Facilities Management

Nashville, IN - USA

Monthly Salary: Not Disclosed

Posted on: 16 hours ago

Vacancies: 1 Vacancy

Job Summary

Director of Accreditation and Facilities Management

This is a hybrid position based at our corporate office in Brentwood TN with on-site work required Monday through Wednesday.

Position Overview:
The American Group Director of Accreditation and Facilities Management is responsible for leading and overseeing the healthcare organizations accreditation and facilities management programs across all hospitals. This role ensures the organization meets or exceeds standards set by accrediting bodies federal and state regulations and internal policies. The Director works closely with clinical administrative and operational leaders to promote a culture of compliance patient safety and continuous quality improvement.

Key Responsibilities

Strategic Leadership

Regulatory and Accreditation Strategy

Develop and execute a strategic plan to ensure compliance with all applicable regulations and accreditation standards (e.g. The Joint Commission CMS state health departments).
Monitor changes in regulatory and accreditation requirements and adapt organizational policies and procedures accordingly.

Enterprise-Wide Oversight

Lead the accreditation and compliance programs across the organization including hospitals clinics and other healthcare facilities.
Serve as the subject matter expert and primary liaison for all regulatory and accrediting bodies.

Policy Development

Develop implement and maintain policies and procedures to ensure compliance with regulatory and accreditation standards.
Collaborate with leadership to align policies with organizational goals and best practices.

Operational Management

Survey Preparation and Management

Coordinate and oversee the preparation for accreditation surveys regulatory inspections and other audits.
Conduct mock surveys and readiness assessments to identify and address potential areas of non-compliance.

Performance Monitoring

Establish and maintain systems to track compliance metrics identify trends and report findings to senior leadership.
Oversee corrective action plans to address deficiencies and monitor their implementation and effectiveness.

Education and Training

Develop and deliver training programs for staff and leadership on accreditation and regulatory compliance requirements.
Promote awareness of compliance standards and foster a culture of accountability and continuous improvement.

Collaboration and Stakeholder Engagement

Interdepartmental Coordination

Partner with clinical operational and administrative leaders to integrate compliance and accreditation initiatives into daily operations.
Collaborate with quality risk management and patient safety teams to address gaps and improve outcomes.

External Relations

Serve as the organizations primary contact with accrediting and regulatory agencies.
Respond to inquiries submit required reports and ensure timely resolution of compliance issues.

Patient-Centered Focus

Ensure that all compliance and accreditation efforts prioritize patient safety quality of care and positive outcomes.

Quality Improvement and Risk Management

Quality Initiatives

Lead enterprise-wide initiatives to improve clinical outcomes reduce risks and enhance patient safety.
Align accreditation and compliance efforts with the organizations quality and performance improvement goals.

Risk Mitigation

Identify and mitigate risks related to non-compliance and patient safety.
Conduct root cause analyses for compliance-related incidents and implement preventive measures.

Qualifications

Education:

High School Diploma or equivalent

Experience:

7 years of experience in operations facilities and maintenance work within a healthcare environment
2-3 years in a leadership position
Proven experience managing enterprise-wide compliance and accreditation environment of care emergency management and life safety programs.

Certifications:

Certification in Facilities Management or Plant maintenance preferred

Skills:

In-depth knowledge of regulatory requirements (e.g. CMS ASHRAE NFPA OSHA) and accreditation standards.
Strong leadership organizational and analytical skills.
Proficiency in data analysis compliance tracking tools and reporting systems.
Exceptional communication and interpersonal abilities to foster collaboration and drive change.

Benefits:

Comprehensive health dental and vision insurance
Health Savings Account with an employer contribution
Life Insurance
PTO
401(k) retirement plan with a company match
And more!

ENVIRONMENTAL/WORKING CONDITIONS: Normal busy office environment with much telephone work. Possible long hours as needed. The description is intended to provide only basic guidelines for meeting job requirements. Responsibilities knowledge skills abilities and working conditions may change as needs evolve.

*If you are viewing this role on a job board such as or LinkedIn please know that pay bands are auto assigned and may not reflect the true pay band within the organization.

*No Recruiters Please

Required Experience:

Director

Director of Accreditation and Facilities ManagementThis is a hybrid position based at our corporate office in Brentwood TN with on-site work required Monday through Wednesday.Position Overview:The American Group Director of Accreditation and Facilities Management is responsible for leading and overs...