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Director Accreditation - Risk Management

This job posting is no longer active.

Job ID: 14181
Location: Chapel Hill, NC
Facility/Division: UNC Medical Center
Status: Full Time
Shift: Day Job

Did you know UNC Health has Ranked #2 Most Trusted Healthcare Brand in the U.S.? The UNC Health brand was ranked as the #4 healthcare brand in the United States overall and the #2 most trusted healthcare brand, just after Johns Hopkins and before Mass General. Join our One-Great-Team!

Job Description


Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.

This position is responsible for supervision, oversight and monitoring of the UNC Medical Center’s and other assigned affiliates’ compliance with, state, federal and local regulatory requirements and all accreditation/certification standards such as The Joint Commission, CMS and North Carolina Division of Health Service and Regulation (DHSR). This position also establishes a system to ensure procedures and protocols are consistent with requirements to achieve continuous readiness for regulatory site visits and surveys in collaboration with senior management.

1. Provides leadership in the development and implementation of strategies regarding regulatory compliance. 

2. Directs and coordinates accreditation and regulatory affairs initiatives for UNC Medical Center, and other affiliates as assigned; serves as the organizational liaison with Joint Commission, DHSR and other regulatory agencies. Serves as the representative for external interactions with accrediting and regulatory bodies. 

3. Assesses compliance with accreditation standards and regulations. Identifies key accreditation, regulation and licensing issues and defines areas for improvement. Collaborates with department management and UNC Medical Center leaders. 

4. Analyzes, interprets and makes recommendations to meet federal, state and local requirements. Establishes mechanisms for proactive identification of regulatory issues and tracking of corrective actions. 

5. Monitors for and communicates changes in federal and state regulations, and Joint Commission accreditation standards to hospital leadership and staff. 

6. Provides in-services and continuing education for leadership and staff. Supervises the Accreditation Manager and other staff responsible for coordinating compliance with accreditation and regulatory standards. 

7. Oversees root cause analysis of sentinel events to ensure compliance with Joint Commission framework. Collaborates with the Patient Safety Officer. 

8. Works with the Accreditation Manager to investigate and respond to Joint Commission Complaints. Collaborates with Risk Management as appropriate. 

9. Leads and participates in relevant UNC Health Care committees such as the Accreditation and Standards Committee. Establishes other relevant committees as appropriate such as a Continuous Readiness Committee for UNC Medical Center. 

Other Information

Other information:
Education Requirements:
● Bachelor's degree in health-related field.
Licensure/Certification Requirements:
● No licensure or certification required.
Professional Experience Requirements:
● Seven (7) years of experience of patient care or in healthcare regulatory and accreditation activities in a hospital setting which includes five (5) years of management experience.
Knowledge/Skills/and Abilities Requirements:
● ·Position requires strong written and verbal communication skills to work collaboratively with medical, nursing staff and external review agencies. Knowledge of state and federal regulations, and the Joint Commission standards and practices for acute care hospitals is required. Knowledge of quality improvement and risk management. Demonstrated ability to think critically, develop conceptual strategies.

Job Details

Legal Employer: NC Health

Entity: Shared Services

Organization Unit: Risk Management 

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Schedule: Day Job

Location of Job: US:NC:Chapel Hill

Exempt From Overtime: Exempt: Yes

This is a State position employed by UNC Health Care System.
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Diversity Statement

The UNC Health System and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.

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