Hybrid Director of Accreditation and Licensure

at Wellstar Health System

• Job title: Director of Accreditation and Licensure
• Job type: Full Time
• Experience level: Lead
• Salary: Not specified
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, Virtual, United States

About the role

• Director overseeing accreditation and licensure at one of Georgia’s largest health systems. Ensuring regulatory compliance and continuous survey readiness across multi-facility healthcare organization.

Responsibilities

• The Director of Accreditation & Licensure reports to the Exec. Director Accreditation and Licensure.
• Provides expertise and consultation on The Joint Commission (TJC), Georgia Department of Human Resources (DHR), Center for Medicare and Medicaid Services (CMS), and other regulatory standards and requirements.
• Responsible for development and provision of strategies to support continuous survey readiness (CSR) activities, link CSR to safety, and compliance across the healthcare system.
• Keeps Senior Leadership informed of Wellstar's survey readiness status.
• Develops strategies to support continuous survey readiness activities across the system.
• Provides consultation on strategies to support Disease Specific Certifications.
• Monitors and tracks areas of non-compliance; facilitates barrier removal.
• Develops and implements a reliable process for periodic review and revision of policies and procedures.
• Drives continuous survey readiness through leading The Joint Commission Steering Committee and serves as liaison between system and TJC.

Requirements

• Bachelor's Degree BS degree in a healthcare related field
• All certifications are required upon hire unless otherwise stated.
• HCQM - Cert Healthcare Quality Mgt-Preferred within 1 Year
• Minimum 5 years experience in coordinating regulatory agency survey activities.
• Must have strong interpersonal skills.
• Be able to multi-task.
• Be flexible, organization skills to support a multi-component system.
• Travel between components, occasional out of town travel for seminars, etc.

Benefits

• Join us and discover the support to do more meaningful work—and enjoy a more rewarding life.
• Connect with the most integrated health system in Georgia, and start a future that gives you more. More Than A Career. A Purpose.
• Nationally ranked and locally recognized for our high-quality care and inclusive culture, Wellstar is one of Georgia’s largest and most integrated healthcare systems.
• Every day, 24,000+ of us work together to provide personalized care for patients at every age and stage of life – and our team members are the foundation of that care.