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Job Title:

Department:

Scope of Position 

The Accreditation Senior Officer is responsible for implementing the administrative aspects of the accreditation strategies developed by the Associate Director of Accreditation and Licensure. This will include the monitoring of operationalizing policies and procedures, conducting accreditation and regulatory audits and drills, monitoring compliance, and assisting with continual survey readiness. The Accreditation Senior Officer will work directly with providers and staff to assure provision of high quality patient care while ensuring regulatory compliance of all current and planned inpatient hospital operations and all ambulatory sites including The James Outpatient Care, Stephanie Speilman Comprehensive Breast Center, Martha Morehouse Tower, Millrun, University Hospital Pavillion, Clinical Trials Unit, New Albany, Dublin, Powell, all mammography regional sites, and all future provider-based locations.

This position assists in directing the hospital's operations & activities to comply with all accreditations, regulation, & licensing requirements for all health care sites & services across the continuum. Translates various accrediting, regulatory & licensing agency requirements into action plans to achieve positive survey/audit reviews and implement systems to effectively monitor compliance to standards & to implement new processes to meet new requirements. This position serves as a professional resource throughout the health system to interpret Joint Commission standards, Ohio Department of Health (ODH), Center for Medicare/Medicaid Services (CMS) regulations and other accrediting agencies (e.g. Commission on Cancer, National Association of Programs for Breast Certification) applicable to the hospital and ambulatory environment. Works collaboratively with OSUMC for facilities, life safety and emergency preparedness.

Position Summary 

The Accreditation Senior Officer is responsible for the day-to-day monitoring of compliance with accreditation and regulatory bodies for The James-OSUMC Comprehensive Cancer Center. The Accreditation Senior Officer reviews and analyzes laws, regulations, and accreditation standards to determine operational impact.
Prepares documents and reports related to policies and procedures, accreditation, and regulatory functions. Monitor hospital compliance for accreditation to include The Joint Commission, Conditions of Participation, ODH, CMS, and others as determined appropriate. In addition to these regulatory bodies, the Accreditation Senior Officer will assist with the Commission on Cancer, and the accrediting bodies such as the National Accreditation Program for Breast Centers (NAPBC) and other voluntary disease accreditation programs supported by The James. Works collaboratively with OSUMC for facilities, life safety and emergency preparedness.

Required Qualifications

Master’s degree in health-related field or equivalent combination of education and experience. 4 years of relevant experience required. 4-8 years of relevant experience preferred. Clinical, hospital operations, quality and regulatory background highly desirable.

Additional Information:

Location:

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Scheduled Hours:

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The university is an equal opportunity employer, including veterans and disability.