Title: Accreditation Compliance Officer
Department Org: Quality Management - 110050
Employee Classification: J1 - Salaried Full Time HSC
Bargaining Unit: Professional Staff Association
Primary Location: Health Science Campus Hospital
Start Time: 0800 End Time: 0500
Posted Salary: Salary to commensurate with education and
On Call: False
Responsible for coordination and monitoring of the hospital medical
accreditations, certifications, and regulatory compliance survey
processes to include Center for Medicare and Medicaid Services,
Joint Commission, Ohio Department of Health, and other disease
specific programs. Stays abreast of program manuals/standards,
laws, and regulations that affect organizational compliance. Acts
as a liaison to government agencies and coordinates clinical site
visits for regulators.
Prepares all documents for Joint Commission applications and other
certification programs. Prepares and presents vulnerabilities and
compliance reports to Senior Leadership Team. Completes ODH
hospital registration documents and responds to all requests from
regulatory bodies related to complaint surveys, onsite surveys, and
related action plans. Investigates potential compliance violations
and prepares corrective action plans as necessary. Performs ongoing
education and conducts audits and mock surveys to track compliance
with standards to maintain a continuous state of readiness. Reports
directly to Senior Leadership and Chief Medical Officer.
• Bachelor’s Degree required.
• Five (5) year’s previous experience in a hospital environment
• Five - Seven (5-7) year’s previous experience involving medical
regulatory, hospital accreditation and/or certification programs
• Understanding of the hospital performance improvement and use of
performance improvement statistical tools.
• Project management and audit experience.
• Experience in formal/informal training and educational program
Communication and other skills:
• Establishes relationships and networks across a broad range of
people and groups, including physicians.
• Protects privacy and confidentiality, handles highly sensitive
• Shares information, observations, and conclusions clearly and
• Demonstrates effective and culturally appropriate
• Utilizes effective communication to provide excellent
• Able to graph and analyze data
• Adheres to principles of infection control.
• Serves as an Ambassador of the University of Toledo in the
community, demonstrating the institution’s values, service, and
• Certified Compliance Professional Preferred
Conditions of Employment:
To promote the highest levels of health and well-being, the
University of Toledo campuses are tobacco-free. To further this
effort, the University of Toledo Health Science Campus Medical
Center is requiring candidates for employment to be nicotine-free.
Pre-employment health screening requirements will include cotinine
(nicotine) testing, as well as drug and other required health
screenings for the position. With the exception of positions within
University of Toledo Main Campus and the University of Toledo
College of Medicine and Life Sciences, the employment offer is
conditional upon successful completion of a cotinine test and
Occupational Health clearance.
Equal Employment Opportunity Statement:
The University of Toledo is an equal opportunity, affirmative
action employer. The University of Toledo does not discriminate in
employment, educational programs, or activities on the basis of
race, color, religion, sex, age, ancestry, national origin, sexual
orientation, gender identity and expression, military or veteran
status, disability, familial status, or political
The University is dedicated to the goal of building a culturally
diverse and pluralistic faculty and staff committed to teaching and
working in a multicultural environment and strongly encourages
applications from women, minorities, individuals with disabilities,
dual-career professionals and covered veterans.
The University of Toledo provides reasonable accommodation to
individuals with disabilities. If you require accommodation to
complete this application, or for testing or interviewing, please
contact the Human Resources Department at 419-530-4747 between the
hours of 8:30AM and 5:00PM or apply online for an accommodation
Computer access is available at most public libraries and at the
Office of Human Resources located in the Center for Administrative
Support on the Main Campus of the University of Toledo.
Advertised: 25 Oct 2023 Eastern Daylight Time