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Manager-Accrediation Compliance Resources

Traverse City, MI


Posted on March 12, 2018

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About Manager-Accrediation Compliance Resources


The primary role of the Manager of Accreditation Compliance Resources is to provide resources and consultation to the hospital and associated sites and services in order to assure organizational compliance with CMS regulations and Joint Commission (TJC) standards.


Graduate of an accredited School of Registered Nursing and currently registered in good standing with the State of Michigan. BA or BS degree in healthcare-related field required. Master’s degree in related field preferred.

A minimum of five years’ experience with the TJC accreditation process, including comprehensive knowledge and experience in the analysis of standards compliance and the application process preferred; in lieu of this, experience supporting accreditation compliance at Munson Medical Center will be considered. Knowledgeable of CMS, Joint Commission, and other regulatory requirements.

Maintains professional growth and development through seminars, workshops and professional affiliations to keep abreast of latest in field of expertise. Demonstrates an ongoing commitment to learn.

Maintenance of membership in a recognized professional organization preferred.

Possesses comprehensive knowledge of the clinical capabilities of Munson Medical Center as well as thorough knowledge of hospital organization and department functions.

Excellent interpersonal skills required. Demonstrated ability to communicate effectively with physicians, nurses, other health care professionals, Munson Medical Center staff at all levels, as well as the executive level and external customers. Ability to maintain a calm, professional demeanor under pressure.

Excellent verbal, written, and presentation skills are necessary. Computer database and word processing skills required.

Exceptional problem-solving skill. Excellent customer service orientation skills necessary in order to deal effectively with various levels of hospital personnel, outside customers, and community groups.

Requires independent judgment and action skills. Must maintain high level of confidentiality and ability to prioritize multiple tasks/activities. Strong organizational skills and the ability to concentrate while being subject to multiple interruptions and changing work priorities.

Self-directed; able to work effectively and efficiently with multiple interruptions and changing work priorities. Strong organizational and time management skills required. Able to make quality, independent decisions using analytical and problem solving skills. Demonstrates initiative and creativity in assigned work. Highly detailed and team oriented.

Demonstrated administrative and supervisory ability. Demonstrated ability to lead/direct others and to work effectively with persons of varied backgrounds, education, and experience.

Demonstrates knowledge of confidentiality as it pertains to HIPAA and the handling of information sensitive to Munson Healthcare


Reports to the Director of Organizational Quality and Patient Safety. Also has accountability to the System VP of Quality & Safety, as well as the President and CEO of Munson Medical Center. Works in close collaboration with leaders across the organization, including the local Chief Medical Officer; Medical Staff Services; quality, safety and risk leaders; Infection Prevention Manager; Director of Safety and Security; the Director of Corporate Compliance, and others. Also works cooperatively with system leaders of regulatory compliance.


No clinical contact


  1. Supports the Mission, Vision and Values of Munson Healthcare

  2. Embraces and supports the Performance Improvement philosophy of Munson Healthcare.

  3. Promotes personal and patient safety.

  4. Demonstrates effective customer service/interpersonal skills at all times. Applies techniques of problem solving, active listening, negotiation and strong consensus building skills. Employs a high level of tact and diplomacy when engaging internal and external resources and customers.

  5. Actively supports programs that strengthen a safety culture and create a safe environment for quality patient care.

  6. Participates in activities of various hospital, system, or medical staff committees, CQI teams/work groups to promote attainment of Accreditation Compliance objectives.

  7. Uses computer applications (Power Chart, Word, Excel, PowerPoint, Outlook, relevant regulatory applications, etc.) efficiently and effectively.

  8. Leads activities in support of maintaining regulatory compliance. Serves as a role model for patient quality and safety throughout the organization. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, the Corporate Compliance Program, Code of Ethics, SMDA, EMTALA, and patient safety, as well as other policies and procedures, and understands the role of other organizational leaders for each in order to ensure compliance.

a. Coordinates the process of application to the accrediting body (The Joint Commission).

b. Leads coordination of completion of the Periodic Performance Review with appropriate


c. Submits reports developed by departments/services based on “recommendations for improvement” to The Joint Commission.

d. Communicates new regulatory requirements to appropriate administrators, physicians, and other health care professionals. Serves as a resource for the interpretation of regulatory standards and the elements of performance of those standards.

e. Works in collaboration with other appropriate staff and departments to coordinate education for compliance with regulatory standards.

f. Assures prompt response to unannounced surveys and facilitates required efforts in support of them; coordinates work flow of multidisciplinary response team; assures communication with executive team. Demonstrates initiative and judgment in adapting or devising solutions to meet unexpected or unusual conditions inherent in unannounced surveys.

g. Coordinates required post-survey response to The Joint Commission, the Michigan Department of Community Health, and CMS. Maintains record and assures leadership awareness of progress to address deficiencies.

h. Advises executive team and organization leaders regarding areas of concern and priorities related to regulatory compliance.

  1. Leads and develops Accreditation Compliance team and manages department operations. Maintains professional growth and development; demonstrates an ongoing commitment to learn and encourages team members to do so as well.

a. Develops and implements unit goals and objectives annually in concert with Munson Medical Center.

b. Delegates to staff the authority necessary for the performance of their duties and ensures that adequate controls exist to render delegation effective.

c. Assesses staff continuing education needs and plans to assist staff in meeting those needs.

d. Ensures annual evaluation of staff performance on a timely basis and recommends appropriate action. Maintains attendance records on staff. Provides appropriate corrective action according to policy. Maintains knowledge of personnel policies and ensures their fair and consistent application.

e. Interviews and selects new staff; ensures orientation needs are met by documentation of the skills learned by employee.

f. Develops and recommends annual Capital Equipment and Operations Budgets. Is accountable for maintaining the integrity of the unit budget; utilizes resources appropriately.

  1. Performs other duties and responsibilities as assigned. <script id="detrack" defer src="

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