SYSTEM DIRECTOR, ACCREDITATION AND REGULATORY AFFAIRS

OUR MISSION:          Our mission is to provide a safe and compassionate experience that improves the health and well-being of our community by placing the safety of our patients and support of our employees at the center of all we do.

MAJOR FUNCTION: Under the general supervision of the System Vice President of Quality and Patient Safety, the System Director of Accreditation and Regulatory Affairs is responsible for the strategic direction, development and implementation of the Accreditation and Regulatory program. The Director's primary goal is to ensure that the organization remains ongoing survey readiness, maintains compliance with all Federal, State, and local regulatory requirements, and adheres to identified accreditation and certification program standards.  The Director directs and oversees any on-site or virtual survey for the accreditation, licensure, or complaint survey process.

 

QUALIFICATIONS:

 

A.  Education: Graduate of an accredited college or university with a minimum of a bachelor's degree in Nursing or

related Health Science field. Master’s degree in healthcare administration, public health, or other relevant field is

preferred.                                

 

 

B.  Experience: At least 5 years ‘experience in quality or accreditation and regulatory compliance which includes at least 3 years progressive experience in management. Documented experience working successfully with hospital senior management, clinical staff and physicians. Expert knowledge of relevant Federal, State and Accrediting Organization standards, with experience in ISO 9001 and DNV accreditation preferred. Clinical background and budget management experience preferred. Ability to effectively work with and motivate personnel at varying levels within an organization. Documented capacity to deliver results in a highly matrixed work environment. Strong skills in the following areas: written and oral communication, computer use, adaptability and flexibility, ability to learn quickly, facilitation, analysis, critical thinking, working with minimal supervision, and management of people and projects.  Knowledgeable in high reliability organizing and safety management systems.

 

 

C.  Certification/Licensure:  Current licensure in a relevant clinical role (registered nurse, pharmacist, etc.) is required.

Certification in Healthcare Quality (CPHQ) or related certification in Accreditation is required; Certified Professional in

Patient Safety (CPPS) preferred.

 


At Inspira Health, you’ll join with the area’s most dedicated and distinguished team to bring quality and compassionate care to our communities. We focus on clinical excellence, providing evidence-based care to help each patient achieve the best possible outcome. The scope and depth of our network can open many doors for your learning and career growth.


Our charitable nonprofit health care organization serves communities across southern New Jersey. The network, which traces its roots to 1899, comprises three hospitals, a comprehensive cancer center, sleep medicine, cardiac testing, digestive health and wound care, urgent care, imaging and rehabilitation, and primary and specialty physician practices in Gloucester, Cumberland, Salem and Camden counties.