Manager, Accreditation and Readiness (RN or LPN), Quality Resource Services

Job Title: Manager

Location: Williamson Street

Department Name: Quality Resource Services

Req #: 0000217525

Status: Salaried

Shift: Day

Pay Range: $95,000.00 - $120,000.00 per year

Pay Transparency:

The above reflects the anticipated annual salary range for this position if hired to work in New Jersey.

The compensation offered to the candidate selected for the position will depend on several factors, including the candidate's educational background, skills and professional experience.

Job Overview:

The Accreditation and Readiness Manager oversees organizational compliance with regulatory, licensing, and accreditation standards to ensure continuous readiness for surveys and audits,

This role coordinates internal assessments, develops education and training programs, and partners with leadership and staff to maintain a culture of quality, safety, and regulatory compliance.

Qualifications:

Required:

• Bachelor's degree in healthcare administration, nursing, or related field
• In depth knowledge of accreditation standards Joint Commission, CMS, state regulations
• Strong organizational and project management skills
• Excellent communication, facilitation, and problem-solving abilities
• Ability to engage staff at all levels and foster a culture of continuous readiness

Preferred:

• Master's degree in healthcare administration, nursing, or related field
• 3-5 years of healthcare work experience
• Experience in accreditation, compliance, quality management, or regulatory readiness healthcare
• RN or LPN

Essential Functions:

• Lead ongoing readiness activities to ensure compliance with accreditation bodies e,g, The Joint Commission, CMS, and state licensing agencies
• Conduct regular mock surveys, tracers, audits, and assessments across departments
• Monitor corrective actions and ensure timely resolution of identified gaps
• Evaluate requirements related to applicable accreditation and regulatory agencies and patient safety practices and outcomes
• Participate in activities that prepare the organization for regulatory accreditation
• Develop materials regarding regulatory compliance and patient safety and communicate information throughout the hospital
• Monitor improvement action plans relating to accreditation compliance
• Develop Joint Commission preparation timelines and follow-up to successfully meet survey goals
• Conduct periodic medical record documentation compliance reviews and report findings to appropriate leaders
• Remain up-to-date with current regulatory, accreditation and license standards
• Conduct regular readiness tracers activities in partnership with other internal subject matters such as infection prevention, pharmacy, nursing and other departments
• Assist the Director of Quality with Regulatory and Accreditation Surveys
• Review and maintain policies, procedures, and documentation to align with regulatory requirements with support from Quality Resource team
• Ensure records and reports are accurate, accessible, and survey ready at all times
• Ensure policies and procedures are aligned with regulatory standards
• Develop and deliver staff training programs on accreditation standards, compliance requirements, and best practices
• Act as a subject-matter expert and resource for leadership and frontline staff
• Collaborate with Quality and Patient Safety teams to integrate compliance with performance improvement initiatives
• Analyze compliance data, identify trends, and recommend strategies to strengthen quality outcomes
• Collaborate with the Director of Quality and PI and identify opportunities for improvement with the healthcare system
• Monitor development and use of metrics for accreditation compliance and required quality improvement activities

Benefits and Perks:

At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees’ physical, emotional, social, and financial health.

• Paid Time Off (PTO)
• Medical and Prescription Drug Insurance
• Dental and Vision Insurance
• Retirement Plans
• Short & Long Term Disability
• Life & Accidental Death Insurance
• Tuition Reimbursement
• Health Care/Dependent Care Flexible Spending Accounts
• Wellness Programs
• Voluntary Benefits (e.g., Pet Insurance)
• Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!

Choosing RWJBarnabas Health!

RWJBarnabas Health is the premier health care destination providing patient-centered,high-qualityacademic medicine in a compassionate and equitable manner, whiledelivering abest-in-classwork experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.

RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey—whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.

RWJBarnabas Health is an Equal Opportunity Employer