Director of Accreditation and Facilities Management

Overview

This hybrid position is based at our corporate office in Brentwood, TN, with on-site work required Monday through Wednesday. The American Group Director of Accreditation and Facilities Management is responsible for leading and overseeing the healthcare organization's accreditation and facilities management programs across all hospitals. This role ensures the organization meets or exceeds standards set by accrediting bodies, federal and state regulations, and internal policies.

The Director works closely with clinical, administrative, and operational leaders to promote a culture of compliance, patient safety, and continuous quality improvement.

• Regulatory and Accreditation Strategy
• Develop and execute a strategic plan to ensure compliance with all applicable regulations and accreditation standards (e.g., The Joint Commission, CMS, state health departments).
• Monitor changes in regulatory and accreditation requirements and adapt organizational policies and procedures accordingly.
• Enterprise-Wide Oversight
• Lead the accreditation and compliance programs across the organization, including hospitals, clinics, and other healthcare facilities.
• Serve as the subject matter expert and primary liaison for all regulatory and accrediting bodies.
• Policy Development
• Develop, implement, and maintain policies and procedures to ensure compliance with regulatory and accreditation standards.
• Collaborate with leadership to align policies with organizational goals and best practices.

• Survey Preparation and Management
• Coordinate and oversee the preparation for accreditation surveys, regulatory inspections, and other audits.
• Conduct mock surveys and readiness assessments to identify and address potential areas of non-compliance.
• Performance Monitoring
• Establish and maintain systems to track compliance metrics, identify trends, and report findings to senior leadership.
• Oversee corrective action plans to address deficiencies and monitor their implementation and effectiveness.
• Education and Training
• Develop and deliver training programs for staff and leadership on accreditation and regulatory compliance requirements.
• Promote awareness of compliance standards and foster a culture of accountability and continuous improvement.

• Interdepartmental Coordination
• Partner with clinical, operational, and administrative leaders to integrate compliance and accreditation initiatives into daily operations.
• Collaborate with quality, risk management, and patient safety teams to address gaps and improve outcomes.
• External Relations
• Serve as the organization’s primary contact with accrediting and regulatory agencies.
• Respond to inquiries, submit required reports, and ensure timely resolution of compliance issues.
• Patient-Centered Focus
• Ensure that all compliance and accreditation efforts prioritize patient safety, quality of care, and positive outcomes.

• Quality Initiatives
• Lead enterprise-wide initiatives to improve clinical outcomes, reduce risks, and enhance patient safety.
• Align accreditation and compliance efforts with the organization's quality and performance improvement goals.
• Risk Mitigation
• Identify and mitigate risks related to non-compliance and patient safety.
• Conduct root cause analyses for compliance-related incidents and implement preventive measures.

• Education:
  • High School Diploma or equivalent
• Experience:
  • 7+ years of experience in operations, facilities and maintenance work within a healthcare environment
  • 2-3 years in a leadership position
  • Proven experience managing enterprise-wide compliance and accreditation environment of care, emergency management, and life safety programs.
• Certifications:
  • Certification in Facilities Management or Plant maintenance preferred
• Skills:
  • In-depth knowledge of regulatory requirements (e.g., CMS, ASHRAE, NFPA, OSHA) and accreditation standards.
  • Strong leadership, organizational, and analytical skills.
  • Proficiency in data analysis, compliance tracking tools, and reporting systems.
  • Exceptional communication and interpersonal abilities to foster collaboration and drive change.

• Comprehensive health, dental, and vision insurance
• Health Savings Account with an employer contribution
• Life Insurance
• PTO
• 401(k) retirement plan with a company match
• And more!

ENVIRONMENTAL/

WORKING CONDITIONS:

Normal busy office environment with much telephone work. Possible long hours as needed. The description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.

• If you are viewing this role on a job board such as  or Linked In, please know that pay bands are auto assigned and may not reflect the true pay band within the organization.
• No Recruiters Please