Director - Accreditation Readiness

Roanoke, VA, US, 24014

Job Summary

Be at your best with an organization that equips you to do so.  Whose people unite in making lives better. At Carilion Clinic, we help communities stay healthy and our region grow stronger through compassionate care, medical education and research, and neighborhood outreach. As part of our team you can expect professional stability, strong technological resources, and the advancement potential of a regional leader.


Support Carilion’s hallmarks of service excellence and quality for all job responsibilities.  Provide leadership and direction for ongoing accreditation readiness including all hospitals, home health, hospice, Joint Commission surveyable ambulatory locations, and all other applicable sites across the system.  Work with all stakeholders – physicians, staff, and management – to champion a patient-focused and outcome-oriented culture in which meeting accreditation standards are viewed as an essential part of overall quality and patient safety.  Provide consultation and assistance in the development and use of policies and procedures in a manner which not only assures an integrated approach to accreditation and regulatory compliance but also promotes strong clinical outcomes and effective operations.  Serve as the principal organizational liaison with Joint Commission.  Serves as the Joint Commission standards subject matter expert, including cross walked CMS Conditions of Participation for accreditation, to support policy and procedure processes/functions for Carilion Clinic.  In collaboration with CAPS leadership, supports CMS and state surveys, as needed.  Participates in Carilion Clinic medical staff activities related to accreditation.  Participates as a member of the system quality and patient safety teams.


Manages compliance with accreditation standards and effective processes for the consistent interpretation and application of accreditation standards across Carilion Clinic.  Maintains an effective process to evaluate all pertinent parts of Carilion Clinic for compliance with accreditation standards on an ongoing basis; example evaluations would be mock surveys, tracers, unit/clinic rounding, audits, and similar assessments.  Ensures the process identifies possible vulnerabilities and opportunities for improvement related to accreditation.  Monitors performance, develops and reviews metrics, assesses and prioritizes risk.  Oversees reporting of compliance and risks to appropriate managers, directors, and their leadership.  Provides status/results to senior management on an ongoing basis.


Oversees activities of Carilion Clinic’s Accreditation Readiness Department.  May provide leadership support for other areas within Clinical Advancement and Patient Safety.  Ensures the proactive maintenance of accreditation for all Carilion surveyable facilities.  Will manage extensive contact with Joint Commission.  Travel to other Carilion sites.  Accountable for maintaining confidentiality of patient and organizational information.


Based in Roanoke, VA, we are an award-winning, community-based network of hospitals, primary and specialty physician practices, and affiliations with prestigious academic medical institutions. Explore how joining a regional leader can enhance your ability to learn, grow, and succeed.

Minimum Qualifications

Education:  Healthcare degree required.  RN preferred.  Master’s degree in related field or Bachelor’s degree plus eight (8) years of progressive healthcare leadership experience.  Strongly desired:  Formal education in organizational development and change management.


Experience: Required for hiring:  Four (4) years of experience in accreditation/regulatory compliance or a related field.  Strongly desired:  Significant experience in hospital accreditation and a high degree of expertise in Joint Commission standards experience in leading change in a complex organization.  Facilitation training and/or experience.  Training and/or experience in organizational development, basic performance improvement techniques, project management and change management.


Licensure, certification, and/or registration:  Required within 24 months of starting:  Certification as Certified Joint Commission Professional (CJCP), Certified Professional in Healthcare Quality (CPHQ), or similar certification approved by the VP Quality and Patient Safety.


Other Minimum Qualifications: Excellent written and verbal communication skills.  Ability to resolve problems, facilitate interdisciplinary teams, creatively overcome barriers to success, and develop staff.  Experience with word processing, spreadsheet computer software, presentations, and basic data analysis/interpretation.  Excellent organizational skills.  Excellent interpersonal skills necessary to interact with a variety of individuals.  Demonstrated skills in training and consultation techniques.  Must have the ability to be flexible, prioritize, organize and complete assignments in a timely manner.  Must have the ability to work outside normal working hours on a periodic basis, such as during a Joint Commission survey.  Must be willing to travel regularly across Carilion Clinic.  Must be able to work with a minimal amount of supervision.

Our Values

Below are our core values that we strive to embody and expect of all our team members:

Collaboration: Working together with purpose to achieve shared goals.

Commitment:  Unwavering in our quest for exceptional quality and service.

Compassion:  Putting heart into everything we do.

Courage:  Doing what’s right for our patients without question.

Curiosity:  Fostering creativity and innovation in our pursuit of excellence.


Requisition Number: 91153 
Employment Status: Full time 
Location: CRMH - Carilion Roanoke Memorial Hospital 
Shift: Day 
Shift Details: Prim. Monday - Friday with 24 hour accountability
Recruiter: DANA E JOHNSON 
Recruiter Phone: 540-400-4631
Recruiter Email: dejohnson@carilionclinic.org
For more information, contact the HR Service Center at 1-800-599-2537.

This is Carilion Clinic ...

An organization where innovation happens, collaboration is expected and ideas are valued. A not-for-profit, mission-driven health system built on progress and partnerships. A courageous team that is always learning, never discouraged and forever curious.

Headquartered in Roanoke, Va., you will find a robust system of award winning
hospitals, Level 1 and 3 trauma centers, Level 3 NICU, Institute of Orthopedics and Neurosciences, multi-specialty physician practices, and The Virginia Tech Carilion School of Medicine and Research Institute.

Carilion is where you can make your own path, make new discoveries and, most importantly, make a difference. Here, in a place where the air is clean, people are kind and life is good. Make your tomorrow with us.

Equal Opportunity Employer

Minorities/Females/Protected Veterans/Individuals with Disabilities/Sexual Orientation/Gender Identity

Carilion Clinic is a drug-free workplace.


Nearest Major Market: Roanoke

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