Associate Director, Accreditation and Compliance

Associate Director, Accreditation and Compliance page is loaded## Associate Director, Accreditation and Compliancelocations: Health System Shared Servicestime type: Full timeposted on: Posted Yesterdayjob requisition id: R150371Screen reader users may encounter difficulty with this site. For assistance with applying, please contact View email address on click.appcast.io. If you have questions while submitting an application, please review these .**Current Employees and Students:**If you are currently employed or enrolled as a student at The Ohio State University, please log in to to use the internal application process.Welcome to The Ohio State University's career site. We invite you to apply to positions of interest. In order to ensure your application is complete, you must complete the following:* Ensure you have all necessary documents available when starting the application process. You can review the additional job description section on postings for documents that may be required.* Prior to submitting your application, please review and update (if necessary) the information in your candidate profile as it will transfer to your application.## Job Title:Associate Director, Accreditation and Compliance## Department:James | Oncology Nursing Administration**Scope of Position**The position provides strategic leadership and oversight for all accreditation, regulatory compliance, and life safety activities across The James Cancer Hospital and Solove Research Institute. It is responsible for conducting assessments, coordinating education, managing surveys and responses, and implementing systems to monitor compliance with evolving standards. The role prepares and submits required documentation to local and national regulatory bodies, evaluates the effectiveness of corrective actions, and supports continuous quality improvement to ensure safe, high‐quality, and compliant healthcare delivery. It ensures organizational policies align with legal and regulatory requirements and provides education on policy updates. Serving as a subject matter expert for the Comprehensive Cancer Center program, the leader interprets standards and regulations from bodies such as the Joint Commission, Ohio Department of Health (ODH), Centers of Medicare and Medicaid Services (CMS), and Columbus Public Health, while also supporting additional accreditations including the Commission on Cancer. The position oversees hospital licensing, coordinates ODH-related activities, and leads Emergency Preparedness efforts for the organization.**Position Summary**The Associate Director of Accreditation and Compliance is responsible for management of departmental operations, evaluation of employee performance, ensures the department demonstrates customer satisfaction and strategic, operational planning and program development. Has a strong working knowledge of ongoing monitoring techniques (including total quality management principles, tools, & techniques); clinical operations in hospital & outpatient settings.The Associate Director is responsible for ensuring that the facility remains in compliance with Joint Commission, State and Federal standards with oversight and responsibility for all regulatory body surveys, i.e., Joint Commission, State Licensing and Reviews, CMS Validation Surveys, Health Department, local regulatory reviews (fire marshal), and any other regulatory activity that involves the facility. This responsibility includes staying current with Joint Commission, state, and local standards, educating facility staff about standards, and preparing the facility for surveys.Plans and coordinates accreditation and regulatory compliance activities to assure safe, high quality and regulatory compliant healthcare delivery. This includes involvement in the development and implementation of hospital-wide performance improvement plans and valuation of effectiveness of corrective actions for identified problems and continuous quality improvement activities.Responsible for the overall leadership of implementation of the organization’s Accreditation and Regulatory Plan; evaluation of the quality of care provided to people receiving support from all organizational entities; and the organization-wide monitoring, analysis, and improvement of program processes. Also responsible for coordinating and directing varied functions in the programs across the organization to provide an integrated approach to quality improvement and management related to regulatory activity.Responsible for ensuring policies are compliant with legal standards, the rules and regulations of regulatory agencies, and that education is provided to the organization on policies and procedures updates.This position coordinates and collaborates with the Enterprise Emergency Preparedness and Life Safety Program at The James.**Minimum Qualifications*** Master's Degree in Nursing or a Healthcare related field or equivalent combination of education and experience.* 6 years’ experience in accreditation survey preparation and coordination.Preferred* 5 years patient care experience* 3 Years in leadership* Hospital or Outpatient management experience, including but not limited to regulatory & licensing, accreditation, performance improvement, risk management and quality assurance in an acute care hospital.* Current experience (within the last three years) with regulatory survey process and development of regulatory plans of correction/action plans.* Knowledge of medical staff oversight/credentialing* Current licensure if applicableOngoing: This person must demonstrate competency to meet essential job functions and the ability to adapt to the rapid changes that occur in the health care setting. Maintains and seeks new knowledge related to regulatory oversight, emergency preparation, current policies, procedures, and protocols. Must meet mandatory educational and health requirements. Experience in databases, spreadsheets, and graphics required. ## Additional Information:## Location:Ackerman Rd, 660 (0242)## Position Type:Regular## Scheduled Hours:40## **Shift:**First Shift***Final candidates are subject to successful completion of a background check. A drug screen or physical may be required during the post offer process.***Thank you for your interest in positions at The Ohio State University and Wexner Medical Center. Once you have applied, the most updated information on the status of your application can be found by visiting the section of this site. Please view your submitted applications by logging in and reviewing your status. For answers to additional questions please review the .The university is an equal opportunity employer, including veterans and disability.At Ohio State, you’ll find work that inspires you. We offer roles and growth opportunities in countless fields and specialties — including a job that’s right for ***you***.### Starting day one: Comprehensive benefits.give you options to take care of what matters most to *you* — and opportunities to make adjustments as your life and needs change, including:• Medical, dental and vision coverage, with Ohio State paying a significant portion of the cost.• Paid time off, including sick and vacation time and 11 holidays.• State retirement plan or an alternative retirement plan, both with generous employer contributions.As Buckeyes, we accomplish more together. No matter your role, you’ll be part of creating what people need now: pathways to education, research and health care.Working at Ohio State means you’re part of a team with a strong sense of community and an unwavering commitment to excellence — and, of course, incomparable Buckeye spirit. We bring out the best in people, help each other succeed and learn together.By joining Ohio State, you become part of a top-20 public university with one of America’s leading academic health centers. #J-18808-Ljbffr