Manager, Accreditation - Unified Quality

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The Accreditation Manager is a member of the UNC Health Unified Quality Accreditation team and reports to the System Director of Accreditation. Team members are assigned to support one or more healthcare system sites while contributing to enterprise priorities and may support other sites based on organizational need.

The position advances a consistent system approach to accreditation by helping translate CMS Conditions of Participation, Joint Commission and DNV standards, North Carolina regulatory requirements, and other applicable requirements into reliable daily practice. In partnership with clinical, operational, and quality leaders, the Accreditation Manager strengthens continuous readiness, coordinates surveys, identifies regulatory risks, and supports sustainable corrective action. Operational leaders remain accountable for compliance within their areas;
Accreditation provides expertise, tools, monitoring, and escalation.

Leads and develops assigned Accreditation team members. Establishes clear expectations, promotes teamwork, provides feedback, and supports accountability and professional development.

Implements UNC Health accreditation strategy, standard work, tools, and governance processes at assigned sites. Serves as a trusted resource to site leaders and contributes to enterprise initiatives that strengthen consistency and reduce duplication.

Maintains current knowledge of CMS, Joint Commission, DNV, North Carolina Division of Health Service Regulation, and other applicable requirements. Interprets standards, communicates changes, and translates requirements into practical guidance.

Leads and supports tracers, audits, rounding, mock surveys, and other readiness activities. Coordinates preparation and response for accreditation, certification, validation, complaint, and regulatory surveys, including immediate actions, written responses, and evidence of compliance.

Uses survey findings, audit results, complaints, and other information to identify regulatory risks and recurring issues. Facilitates corrective action plans, monitors effectiveness and sustainability, and escalates significant or unresolved concerns. Uses influence, sound judgment, and change-management principles to help leaders address barriers and sustain corrective action.

Develops education, tools, and resources that help leaders and teammates understand regulatory expectations and their responsibilities. Partners with policy owners and subject matter experts to align policies and operational practices with applicable requirements.

Collaborates across Unified Quality and with clinical, operational, Risk Management, Environment of Care, Life Safety, Nursing, and Medical Staff leaders. Shares effective practices and lessons across UNC Health.

Travels within North Carolina to UNC Health sites as required. Overnight travel is estimated at up to five nights per month, although travel will not occur every month. Travel frequency is subject to change based on organizational needs.

WAYNE

Bachelor's Degree in Nursing (BSN) or related field.

No licensure or certification required.

Seven (7) years of experience in administration or patient care in a hospital setting. One (1) year of managerial experience required.

Position requires strong written and verbal communication skills. Experience with Microsoft Office and electronic medical record systems desired.

01.8760.NUR-860

Legal

Employer:

Wayne Health

Entity:
Wayne UNC Health Care

Organization Unit:
Perf.

Improvemnt

Work Type:
Full Time

Standard Hours Per Week: 40.00

Work Assignment Type:
Onsite

Work Schedule:

Day Job

Location of Job: WAYNE MED

Exempt From Overtime:
Exempt:
Yes

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability,…