JOB DESCRIPTION

Job Summary:

The Manager of Accreditation is an essential member of the Quality and Population Health team at The Jane Pauley Community Health Center (JPCHC) and is responsible for leading and coordinating all activities to ensure the organization is fully prepared for accreditation by The Joint Commission (TJC) and NCQA Patient-Centered Medical Home (PCMH). This position serves as the primary liaison between JPCHC and accreditation bodies, ensuring compliance with standards, policies, and procedures while driving a culture of continuous improvement and regulatory readiness.

Key Responsibilities:

Accreditation Preparedness and Compliance
• Oversee and coordinate all activities related to TJC and PCMH accreditation processes.
• Conduct readiness assessments, mock surveys, and tracers to identify areas of noncompliance.
• Develop and implement corrective action plans and monitor progress toward achieving
compliance.
• Maintain up-to-date knowledge of accreditation standards, policies, and regulatory
requirements.
Policy Development and Implementation
• Ensure organizational policies and procedures align with accreditation standards and
regulatory requirements.
• Collaborate with department leaders to develop, review, and revise policies as necessary.
Training & Education
• Develop and deliver education and training programs for staff and leadership to
promote understanding and compliance with accreditation standards.
• Provide coaching and support to departments to address identified gaps in compliance.
Documentation and Reporting
• Ensure accurate documentation of compliance activities, findings, and improvement
efforts.
• Prepare and submit required reports to accreditation bodies.
Collaboration and Leadership
• Act as a resource and advisor to leadership and staff on accreditation and compliance
matters.
• Foster a culture of continuous improvement by promoting proactive identification and
resolution of compliance risks.
• Serve as the primary contact during accreditation surveys and facilitate interactions with
surveyors

Qualifications

Education
• Bachelor’s degree in Healthcare Administration, Nursing, Public Health, or a related field
required. Master’s degree preferred.
Experience
• Minimum of 5 years of experience in healthcare accreditation, quality assurance, or
compliance.
• Demonstrated knowledge of TJC and NCQA PCMH accreditation standards and
processes.
• Experience leading organizational readiness for accreditation surveys.

Skills & Abilities

• Strong analytical, problem-solving, and organizational skills.
• Excellent written and verbal communication skills.
• Ability to work collaboratively with cross-functional teams and build effective
relationships.
• Proficiency in data analysis and performance improvement methodologies.
• Detail-oriented with the ability to manage multiple projects simultaneously.
• Basic Life Support through AHA required

Work Environment
• Standard office environment with occasional travel to healthcare facilities within the
system.
• Remote work available when appropriate, in consultation with supervisor.
• Must be available during accreditation surveys and periodic after-hours work as needed

Keywords: JPCHC, Jane Pauley, Quality, Population Health

The Jane Pauley Community Health Center offers comprehensive healthcare services to the communities served, regardless of ability to pay. The health centers offer primary care, dental care, and behavioral health services for adults and children. The organization currently serves patients from 16 sites of care across 4 Indiana counties. The Jane Pauley Community Health Center was established in 2009 with generous support from the Metropolitan School District of Warren Township, Community Health Network and the Community Health Network Foundation. It is named after Jane Pauley, a 1968 Warren Central High School graduate who grew up in the area and is well known as the former anchor of NBC-TV's “Today” and “Dateline” programs. Pauley is also the current host of “CBS Sunday Morning.”