Manager, Accreditation and Compliance

Job Description

UC Health is hiring a full-time Manager, Accreditation and Compliance for the first shift. This person will assist all of UC Health.

This person will require high-quality professionalism within our organization.

About UC Health

UC Health is an integrated academic health system serving Greater Cincinnati and Northern Kentucky. In partnership with the University of Cincinnati, UC Health combines clinical expertise and compassion with research and teaching-a combination that provides patients with options for even the most complex situations. Members of UC Health include: UC Medical Center, West Chester Hospital, Daniel Drake Center for Post-Acute Care, Bridgeway Pointe Assisted Living, University of Cincinnati Physicians and UC Health Ambulatory Services (with more than 900 board-certified clinicians and surgeons), Lindner Center of HOPE and several specialized institutes including: UC Gardner Neuroscience Institute and the University of Cincinnati Cancer Center. Many UC Health locations have received national recognition for outstanding quality and patient satisfaction. Learn more at

Department Details :
  • The goal of Accreditation and Regulatory Affairs is to live in a continual state of survey readiness.
    • The requirements set by ODH, CMS and The Joint Commission aim at making the hospital a safe place for patients and our staff.
    • Through attaining a continual state of survey readiness we in turn provide safer care to our patients.
    • Ensuring Policies and Standard Operating Procedures are current, evidence based, and easily accessible is a key part of survey readiness.
  • The Quality Assurance team conducts high level mortality review data, Peer Review, Core Measure abstraction, Blood Transfusion Safety audits, Third Party Quality Reviews, and Patient Safety Indicators (PSI) and Hospital Acquired Conditions (HACs) review.


Under the supervision of the Enterprise Director of Regulatory and Accreditation, the Manager of Accreditation and Regulatory Affairs manages and coordinates the organizational effort to assure continuous compliance with Joint Commission standards, CMS Regulations and any other regulatory bodies. This person also manages projects for campus integration including hospital-based ambulatory care.
  • Serves as the organizational resource on interpretation of Joint Commission standards, CMS Conditions of Participation and ODH by developing and maintaining expert knowledge.
  • 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.
  • Provides education and collaboration to hospital departments and managers to assure current knowledge of appropriate standards.
  • Designs, organizes and implements systems for tracking, evaluation and reporting efforts and outcomes relative to standards set by accrediting and regulatory agencies.
  • Chairs weekly meeting with hospital ambulatory care practice leadership to address any opportunities in the on-boarding process and transition.
  • Directs individuals and departments in the establishment, implementation and stabilization of new services and processes.
  • Works closely with and reports to Senior Leadership to monitor the progress to ensure regulatory compliance from all aspects of TJC, CMS, ODH and Ohio Board of Pharmacy.
  • Coordinates independently projects of high complexity.
  • Provides education and mentoring to managers, staff and physicians to assure attainment of program goals.
  • Coordinates Physician annual education to ensure regulatory compliance.
  • Utilizes diverse communication and education strategies to assure the integration of regulatory compliance practices by all staff, volunteers and physicians utilizes systems thinking to identify causes and solution to errors.


  • Bachelor's Degree is Nursing is required.
  • Master's Degree preferred.
  • Current RN License.
  • Three to five years equivalent experience.
  • Five years clinical experience preferred in multiple areas, plus two years of line or project management experience.
  • Three to five years equivalent experience in clinical data analysis experience in hospital/healthcare setting preferred.
  • Formal training or experience in patient safety preferred.

Join our team as an Accreditation and Compliance Manager, for UC Health and work alongside the best and brightest leaders and administrators collaborating toward our common purpose: to advance healing and reduce suffering.

Join our team to BE UC Health. Be Extraordinary. Be Supported. Be Hope. Apply Today!