“Care” is not merely a word at Southeast Georgia Health System. It’s our promise to our team members, our patients and families, and ourselves—to be the finest professionals possible. As the region’s health care provider and employer of choice, we offer outstanding opportunities, rewarding experiences, and a great quality of life. Join our team, learn what we stand for, and discover how much more you can enjoy your career.
Experience the advantages of excellence
In return for your compassion, clinical expertise, and spirit of commitment, we offer an excellent compensation package, including comprehensive benefits and relocation assistance.
Manager, Accreditation Services
Southeast Georgia Health System Brunswick, GA | Full-time
** Relocation Assistance Available **
Make the most of your specialized credentials to manage the accreditation and certification process for the Health System. We seek a detail-oriented leader to facilitate the compliance with the Joint Commission (TJC) standards for hospital accreditation, to obtain full accreditation for both the Brunswick and Camden campuses. In this key role also will assist and facilitate other accreditation/certifications being sought by the Health System.
Manage and direct implementation of TJC’s Hospital Accreditation Standards Manual program, and chair the monthly Continuous Survey Readiness (CSR) Committee meetings for the two hospitals on the Brunswick and Camden Campuses.
Direct the planning, development, implementation, and refinement of the Health System’s CSR program, with the goal of maintaining full TJC Accreditation for both hospitals.
Ensure the accuracy and timeliness of responses from the CSR Functional Chapter Chairpersons on required submissions (e.g., General Application, annual Periodic Performance Reviews, Evidence of Standards Compliance, Measures of Success, Sentinel Event response) to TJC and the Center for Medicare and Medicaid Services (CMS).
Provide oversight and guidance for all accreditation programs (e.g., CMS annual long-term care facility surveys of our two Senior Care Centers, Sleep Medicine Centers, etc.).
Oversee and assist with complaint surveys.
Manage Health System compliance with TJC and other accrediting organizations, including CMS and the Georgia Department of Community Health.
Manage and direct the 22 Functional Chapter chairpersons (vice presidents, directors, and managers) about ongoing Joint Commission activities and deadlines throughout the year.
Report quarterly on the Health System’s continual survey readiness to the Compliance Committee of the SGHS Inc. Board, and monthly at leadership meetings, and at the Quality and Patient Safety Operations Committee.
Provide ad hoc reports to administration and medical staff on both campuses, as needed.
Direct and collaborate with leadership team and medical staff in the implementation of TJC Standards and National Patient Safety Goals.
Serve on Health System and hospital (Camden and Brunswick campuses) committees, including Patient Care and Safety, EOC/Safety, Provision of Care, Environment of Care, Patient Safety, Pharmacy and Therapeutics, and Falls Prevention Committee.
Participate in environmental rounds and emergency preparedness.
External liaison with national and state accreditation organizations
Cultivate and manage Health System relationships with accreditation organizations.
Attend state and national TJC meetings, and represent the Health System at the state level at the Health System’s Georgia Hospital Association (GHA)/Orion Continual Survey Readiness meetings.
Assume responsibility for overall relationship with our assigned Joint Commission Resources representative, including arrangements for periodic JCR site visits and mock surveys.
Direct leadership team on corrective action and responses to audit findings.
Manage unannounced complaint survey visits or cases for all departments/entities in the Health System from state survey and certification agencies.
Health system policies and procedures management
Directly oversee the Health System’s electronic policy system, Policy Tech, to ensure compliance with TJC, Medicare Conditions of Participation, and other federal, state, and local regulations.
Develop model templates and workflow tools, and lead work groups to create or revise policies and procedures.
Work with the Information Systems Department on periodic Policy Tech updates, and interface with the Health System to ensure proper operation of the online program.
Assist leadership team members in drafting policies to ensure compliance with CMS Medicare Conditions of Participation and other regulations.
Oversee the Health System’s Emergency Access Package and laptop for monthly Policy Tech downloads of all current policies for disaster preparedness purposes.
Education and training
Facilitate and coach leadership, team members, and physicians on best practices and process improvements, and provide ongoing education on new regulations to achieve organizational goals.
Communicate changes with the TJC Standards, National Patient Safety Goals, and the accreditation process to the 22 Functional Chapter chairpersons and leadership at each hospital.
Participate in educational initiatives (e.g., orientation, nurse transition program).
Prepare comprehensive training material on numerous TJC Standards, including “hot sheets” and presentations for team members and medical staff.
Coordinate and direct Tracer Team rounding activity at the hospitals on the Brunswick and Camden campuses, and use tracer methodology, team reports, and self-assessments to maintain an ongoing status of compliance.
At least 5 years of experience in managing hospital accreditation programs, or working in a hospital Quality Department with responsibility for managing accreditation
Nursing license in state of Georgia
Diploma or associate’s degree from an accredited school of nursing required; bachelor’s degree in healthcare-related field, or graduate of a bachelor’s or master’s school of nursing preferred
Certification from the Joint Commission as a Joint Commission Certified Accreditation Professional, upon completion of 2 years in the role
Demonstrated leadership strength in guiding tasks and motivating teams
Solid experience in planning, developing, implementing, and evaluating programs
Strong analytical skills
Superior communication (written and verbal) and communication skills, to confidently interact and partner at various levels, internally and externally, on behalf of the Health System
Organized and detail-oriented in handling multiple priorities and working independently
Supportive, customer service-oriented attitude with a demonstrated ability to attain results
Celebrate your talent today.
For More Information:
Contact Judy Wilbanks, Talent Acquisition Specialist, for more information about opportunities at Southeast Georgia Health System. Please CLICK ON THE APPLY BUTTON to confidentially e-mail her.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, or national origin. EOE/AA: M/F/D/V
Southeast Georgia Health System is a not-for-profit health care network that provides quality care in personal, community settings. Enjoying highly advanced technology, techniques, and facilities, our team members are the key to our success. These unique professionals offer exemplary talent, compassion, ambition, and experience to provide exceptional care for every patient. We embrace them as family, and support their career aspirations with extensive training, access to vast resources, and real advancement potential. If you’re all for making a difference, in many different ways, Southeast Georgia Health System is definitely for you.