Associate Director, Accreditation Services
University of Iowa Health Care seeks a dedicated Associate Director of Accreditation Services to join our team. The role leads activities to assess, plan, monitor, and evaluate compliance with accreditation standards and regulations, including Joint Commission, Centers for Medicare and Medicaid Services (CMS), State of Iowa Department of Inspection and Appeals (IDIA) and other accrediting agencies. The associate director designs, plans, promotes, and conducts educational, service, and other programs about Joint Commission standards compliance assessment and staff education to ensure survey readiness, providing leadership for all accreditation activities hospital-wide, including off-site locations.
Key Responsibilities:
- Lead the planning, development, implementation, maintenance, and oversight of programs to ensure hospital compliance with all state and national regulatory and accreditation standards at University of Iowa Health Care Medical Center, inclusive of all off-site clinics.
- Provide leadership to individuals, groups and departments seeking a new certification with Joint Commission and other accrediting bodies.
- Maintain knowledge regarding accreditation standards, a database, and a reference library of current initiatives by accrediting agencies through timely review of regulatory guidelines, journals, and newsletters, relationships with agency representatives, and attendance at agency educational programs.
- Obtain and disseminate standards, regulations, etc., to those in the health system as necessary.
- Provide leadership to department heads, managers, supervisors, healthcare providers, and staff to ensure that healthcare services are provided in accordance with quality and safety standards established by state and federal regulations and national accrediting bodies.
- Direct implementation of training programs and other educational efforts to ensure all UI Health Care staff are knowledgeable about Joint Commission and CMS standards.
- Manage the Joint Commission database, documenting processes and procedures for improvement in ensuring compliance with the Joint Commission's and other accrediting agencies' accrediting and regulatory standards.
- Drive institutional awareness related to regulatory requirements and prioritize interventions based on risk.
- Prepare reports, proposals, and related materials for submission to state and federal regulatory and accrediting bodies, including applications for Disease Specific Certification Programs required by CMS or the Joint Commission.
- Develop periodic reports to the UI Health Care leadership and other governance and management entities regarding:
- Announced or potential changes in regulations and/or standards
- Monitoring and evaluation of compliance with all current regulations and/or standards
- Progress on implementation of new policies, procedures, and activities needed to ensure continuing compliance
- Planned visits and surveys by external agencies and results of visits.
- Announced or potential changes in regulations and/or standards
- Oversee the UI Hospitals & Clinics Joint Commission Steering Committee and provide regulatory leadership on other institutional committees as requested.
- Manage the Accreditation Services budget.
Required Qualifications
- Master’s degree or an equivalent combination of education and experience required.
- Five to eight years of experience program management in a health care environment.
- In-depth knowledge of Joint Commission Standards and CMS Standards of Participation required.
- Prior experience participating in Joint Commission surveys and state regulatory surveys.
- Demonstrated people skills, and excellent verbal and written communication skills required.
- Must be self-organized, work independently, and have demonstrated team-building skills.
- Proficiency in Microsoft Office applications, including data management, required.
- The position will require frequent travel to regional ambulatory care clinics in the state. The applicant must have a valid Driver’s License and be able to meet the University of Iowa Fleet Safety Program driving standards (University of Iowa Operations Manual Part V, Chapter 19).
- Demonstrated experience working effectively in a welcoming and respectful workplace environment.
Desired Qualifications
- Specialist in Health Care Accreditation certification.
- Poise in teaching and consulting, flexibility and creativity in problem-solving, and excellent interpersonal skills desired.
- Strong organizational, team building, and leadership skills desired.
Application Process: To be considered, applicants must upload a cover letter and resume (under the submission of relevant materials) that clearly address how they meet the listed required and desired qualifications of this position. Job openings are posted for a minimum of 14 calendar days. Successful candidates will be required to self-disclose any conviction history and will be subject to a criminal background check and credential/education verification.
Up to 5 professional references will be requested at a later step in the recruitment process. For questions, contact Sharon Walther at sharon-walther@uiowa.edu.
This position is not eligible for University sponsorship for employment authorization.
Equal opportunity/affirmative action employer
The University of Iowa is an equal opportunity/affirmative action employer. All qualified applicants are encouraged to apply and will receive consideration for employment free from discrimination on the basis of race, creed, color, religion, national origin, age, sex, pregnancy (including childbirth and related conditions), disability, genetic information, status as a U.S. veteran, service in the U.S. military, sexual orientation, gender identity, or associational preferences.
Persons with disabilities who need assistance or accommodations with the application or interview process may contact University Human Resources/Faculty and Staff Disability Services, (319) 335-2660 or fsds@uiowa.edu. For jobs in UI Health care, please contact UI Health care Leave & Disability Administration at 319-356-7543.
