Director - Corporate Accreditation

Job Description

Location: Cincinnati, OH
Department: UCH-741809-UCH Accred Regulatory Affairs
Hours: Hybrid
Shift: First

At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.

As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors.

UC Health is committed to providing an inclusive, equitable and diverse place of employment.

The Director of Accreditation is responsible for leadership in strategic planning and coordination of regulatory requirements and collaborates with others to create a safe and supportive environment for patients, visitors, physicians and associates. Facilitates preparation, coordination and education of UC Health staff activities relating to TJC, CMS and other regulatory bodies as assigned. This includes maintaining a constant state of compliance readiness for surveys. This position establishes mechanisms for the integration of compliance and survey readiness into all relevant organizational processes, functions and services. In cooperation with the Safety Officer, ensures regulatory requirements for a safe environment for patients and staff. Functions as a change agent to improve current processes and systems to comply with regulatory requirements.


Accreditation Leadership:
    • Provides leadership and oversight for system-wide activities ensuring compliance with regulatory and safety standards on behalf of the Quality Assurance and Regulatory Affairs Leader and senior administrative team.
    • Serves as the Enterprise contact for CMS, The Joint Commission, Ohio Department of Health, Ohio Department of Mental Health the purposes of maintaining deemed status per CMS Hospital Conditions of Participation.
    • Responsible for facilitating completion of annual accreditation and certification requirements including annual hospital accreditation applications (TJC), annual State of Ohio Registrations, and various certification applications.
    • Ensures organizational readiness for accreditation and certification surveys by facilitating the development of a formal readiness plan that includes leader rounding and utilization of mock surveys.
    • Serves as regulatory expert and consultant on enterprise accreditation and regulatory issues and maintains proactive, working knowledge of hospital regulations attained through combination of self-study, membership at regional and national accreditation committees, and attendance at one regulatory conference, annually.
    • Manage onsite and virtual survey activity, as well as regulatory requests from hospitals and external agencies, serving in consultative manner to facilitate standards interpretation and compliance.
    • Education: Designs, delegates and provides training through orientation classes and other education offerings for both clinical and non-clinical staff.
    • Coordinates review of official publications from The Joint Commission, CMS and other regulatory agencies and disseminate data to appropriate individuals.
    • Gap Analysis: Oversee and assess organizational learning needs in accreditation and certification compliance requirements.
    • Risk Assessment: Evaluates organizational risk for compliance with regulatory standards and reports that information to system and site leadership on an ongoing basis.
    • Data: Is responsible for coordination of accreditation rounds and data management related to tracking and trending regulatory compliance and performance improvement activities.
    • AMP: Has administrative contract and functional oversight for the Accreditation Manager Plus (AMP) web-based software and associated processes; TJC submissions; and data analysis related to Accreditation and Certification activities.
    • Rounding and Action Planning: Assists departments as they conduct assessments, plan, implement and monitor quality, safety and risk reduction in compliance with intent of the standards.
    • Coordinates activities with various areas/departments to reduce duplication of efforts.

Regulatory Affairs:
  • Support the design of a new system-wide infrastructure/program for regulatory affairs, including the establishment of appropriate enterprise services and coordination with system and site-based leadership to ensure that UC Health proactively anticipates and complies with applicable regulations and minimizes financial risk related to pay-for-performance programs and promotes best outcomes for patients.
  • Maintain thorough knowledge of regulatory and accrediting body requirements. Interpret new laws, standards, and regulations to direct the development, revision, communication, and implementation of new policies, processes, or systems to ensure ongoing achievement of these external requirements
  • Supports Regulatory Oversight and Committee structure, facilitates and leads interdisciplinary project teams and other compliance or safety activities as assigned.
  • Serves as a regulatory expert and resource in developing action plans to ensure compliance with external regulatory bodies.
  • Gap Analysis: Is responsible to ensure each hospital conducts and documents a proactive, risk assessment to meet or exceed current or proposed regulatory requirements.
  • Serves at the enterprise liaison to UC Health Corporate Compliance department. Assists them with the development of auditing priorities, action plans and ongoing audits to ensure compliance.
  • Develops regulatory reports to be presented to UC Health Governing Body.
  • Assists in development of medical staff and resident education related to the potential or known impact on clinical practice related to compliance and regulatory standards.
  • Oversees development and implementation of ongoing regulatory compliance educational training programs of new or revised standards or of key performance indicators, which reflect current compliance and safety outcomes.

Oversight of Policy Program:
  • AAA Oversight of management and administration various documents from request to posting, including the management of modifications and routine internal correspondence.
  • Ensure timely revision of existing policies/contracts.
  • Support the enterprise process & strategy as defined through enterprise standards and policies for management and administration. As appropriate, contribute to or influence company policies/contracts.
  • Provide guidance on matters to internal associates, including training on the use of the Management System.
  • Responsible for routine department support functions, including provision of expertise to identify opportunities to reduces duplicate polies and SOPs across the system.
  • Support Policy Manager in efforts to ensure UC Health Policies and SOPs comply with applicable regulatory standards.


  • Minimum Required-Bachelor's Degree in Nursing or Allied Health
  • Master's degree - Preferred Degree: Master's in either Nursing or Health Care Administration or applicable Master's Degree. Must obtained within 2 years of hire.

  • Preferred: Licensed to practice as Professional Registered Nurse in the State of Ohio.

  • Must have 5 years of health care experience and at least 3 years proven leadership experience working in a healthcare setting. Previous supervisory/management experience in a clinical care setting is preferred.