Accreditation Services Director

Location

US:

DE:

Dover

Post Date

10/7/2026

Category

Professional

Employment Type

Employee

If you care about the opportunity to grow, to make a difference, to build a future and a life, then we just might have the career for you. Care to talk?

Bayhealth Medical Center is Central and Southern Delaware’s healthcare leader with hospitals in Dover and Milford, a s well as stand
-alone Emergency Department in Smyrna and a hybrid E mergency Department and Urgent Care in Milton . We offer various practice settings throughout Kent and Sussex Counties. Bayhealth Medical Center Kent Campus is 90 minutes from Philadelphia, Washington, DC and Baltimore . Our Sussex Campus is 30 minutes to the Delaware beaches and relaxation in the sand!

Bayhealth Medical Center offers a competitive salary and comprehensive benefits package (for eligible positions) including:

• Generous Paid Time Off and Paid Holidays
• Matching 401(k)/403(b) Plans
• Excellent Health, Dental, and Vision
• Disability and Life Insurance options
• On Site Child Care
• Educational Reimbursement
• Health Care and Dependent Care Flex Spending Accounts
• Plus, an array of Voluntary Benefits to include Critical Care Coverage and more!

Location:
Kent Campus Hospital, Dover Delaware

Status: Full Time 80 Hours Biweekly

Shift: Day/ Evening (Exempt)

SALARY RANGE:

-  YEARLY

General

Summary:

This position is responsible for Accreditation and Regulatory activity across the Bayhealth System. This responsibility requires providing oversight of a standard approach across all Bayhealth operating areas.

Serves as a subject matter expert on regulatory/accreditation and licensure standards and all external expectations associated with compliance in this area. Provides oversight and ongoing internal consultation for all external survey-related activities to ensure continual compliance with requirements and ongoing readiness for survey activity. Works closely with organizational leaders to identify and monitor compliance in key critical areas and elevate improvement opportunities on a timely basis.

Provides oversight into the effective use of external consultants as necessary and all processes focused on improvement in this area, such as the use of mock surveys and focused tracer activities. Provides vision and structure to the internal tracer activity program. Provides a standard approach across Bayhealth for education, survey preparation, survey follow-up/corrective action plans, and ongoing GAP analyses of regulatory/accreditation requirements based on current hospital performance.

Provides oversight to the Bayhealth Policy and Procedure process and the Professional Sanction Check Process. Position is responsible for all budgeting, hiring, and performance management of staff in the Accreditation Services Area.

Responsibilities:

• 1. Position provides oversight into the development and implementation of standard processes across all Bayhealth entities which support successful compliance with all external accreditation and regulatory requirements of the Joint Commission (TJC), Delaware Department of Health and Social Services (DDHSS), and the Center for Medicare and Medicaid Services (CMS).
• 2. Ensures that the following structures are in place to accommodate support of a standardized structure: defined committee meeting structure for accreditation/regulatory oversight; processes for GAP analyses and tracking of opportunities to resolution; uniform tracer program for compliance monitoring; processes for issue prioritization and identification/escalation of critical issues; facilitation of ongoing educational program for staff, medical staff and leaders; creation/dissemination of compliance monitoring reports;
  
  and identification of critical…