The Accreditation Manager is responsible for accreditation and regulatory compliance activities for St. Mary's Medical Center (SMMC). Maintains extensive knowledge of current accreditation standards and related state and federal regulations. Provides guidance on the interpretation and application of Joint Commission standards, state and federal regulations. Prepares policies and educational materials required for compliance. Effectively manages Joint Commission surveys utilizing multi-disciplinary team participation. Prepares and coordinates written responses and follow up to survey findings. Ensures organizational readiness and ongoing compliance with standards and regulations across SMMC. Leads activities designed to monitor and improve compliance with standards, including focused tracers, mock surveys, and educational sessions. Coordinates investigations and responses to complaints received from The Joint Commission. Participates in root cause analysis review of sentinel events. Assists with development and monitoring of corrective action plans.
Graduate of Registered Nurse Program, Bachelor's Degree in related field preferred.
3 years of experience in accreditation (preferred), quality, or patient care in hospital setting
CPHQ required within 2 years of hire; CJCP preferred
Primary Location: West Palm Beach, Florida
Facility: Saint Mary's Medical Center
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 2005011925
About Saint Mary's Medical Center
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.