Program Manager Accreditation

Cleveland Clinic · Fairview Hospital

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At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

We all have the power to help, heal and change lives — beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

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Join Cleveland Clinic Fairview Hospital and experience world-class healthcare at its best. Cleveland Clinic Fairview Hospital is a proud Magnet Hospital awarded by the American Nurses Credentialing Center, the highest honor an organization can receive for professional nursing practice. On our team, you will provide stellar care at one of the top healthcare organizations in the nation. 

As Program Manager, Accreditation, you will coordinate hospital accreditation activities and ensure continuous survey readiness across Fairview Hospital, affiliated organizations, and off-site facilities. In this role, you will collaborate with senior leadership to identify and implement targeted interventions that promote a culture of continuous survey readiness and support ongoing compliance with accreditation standards. You will also provide support to other hospitals, particularly those within the West Submarket.

A caregiver in this role works days from 7:30 a.m. -- 4:30 p.m.

A caregiver who excels in this role will:

• Develop, manage, and maintain programs designed to ensure Cleveland Clinic compliance with accreditation and regulatory standards, including those of The Joint Commission (TJC), the Ohio Department of Health (ODH), and the Centers for Medicare & Medicaid Services (CMS).
• Serve as a primary resource for staff to facilitate program operations and provide guidance on accreditation requirements.
• Consult with departments and institutes on all aspects of TJC and other regulatory agency requirements.
• Educate clinical and nonclinical departments and disseminate accurate information regarding certifications, accreditation standards, and regulatory interpretations.
• Participate in the preparation for and support of on-site survey activities, including responding to unannounced surveys.
• Collaborate with departments across the Quality and Patient Safety Institute to promote safe, high-quality patient care and continuous survey readiness.
• Develop, manage, and coordinate projects related to accreditation and regulatory compliance.
• Participate in committees and meetings to support accreditation initiatives and continuous improvement.
• Review accreditation findings and opportunities for improvement, develop plans of correction for submission to the appropriate accrediting organization, and monitor corrective actions to ensure sustained compliance.
• Interpret and apply accreditation standards and standard operating procedures (SOPs) to identify appropriate solutions for individual institutes and departments.
• Develop proficiency in applicable accreditation standards and remain flexible in supporting a variety of accreditation programs and regulatory requirements.
• Provide cross-coverage for other facilities as needed.
• Travel to local Fairview affiliate locations as required.
• Perform other duties as assigned.

Minimum qualifications for the ideal future caregiver include:

• Bachelor's degree in Nursing, Healthcare Administration, Business, Engineering or related field and five years of related experience with Quality Management, Risk Management/Patient Safety and Performance Improvement program or related healthcare experience
• OR Associate’s degree and seven years of experience.
• OR Master’s degree and four years of experience

Preferred qualifications for the ideal future caregiver include:  

• Master’s degree
• Healthcare background
• RN or clinical experience
• Joint commission experience
• Accreditation experience

Physical Requirements:

• Manual dexterity to operate office equipment.
• Ability to lift and transport up to 15 pounds.
• Requires extended periods of standing, walking and sitting.
• Normal or corrected vision and hearing.

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment as required for procedures.

The policy of Cleveland Clinic Health System and its system hospitals (Cleveland Clinic Health System) is to provide equal opportunity to all of our caregivers and applicants for employment in our drug free environment. All offers of employment are followed by testing for controlled substances.

Cleveland Clinic Health System administers an influenza prevention program. You will be required to comply with this program, which will include obtaining an influenza vaccination on an annual basis or obtaining an approved exemption.

Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic Health System facility. 

If applying for a Florida position, please see the following website for more information on the background screening requirements required by the Agency of Health Care Administration: https://info.flclearinghouse.com/

Please review the Equal Employment Opportunity poster. 

Cleveland Clinic is pleased to be an equal employment opportunity employer.

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