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Accreditation Manager - Surgical Serivces (RN Required)

Work Schedule/Days:  Day / Monday - Friday
Employment Type:  Full-Time
Location:  Scottish Rite 
Requisition #:  37328



Coordinates all accreditation and regulatory activities as assigned in collaboration with the Manager, System Regulatory Services. Provides education, consultation, and oversight for all areas of the system to ensure the maintenance of a continual accreditation readiness culture.

  • Bachelor of Science (nursing or related field)

  • Licensure as a Registered Nurse in the single State of Georgia or Multi-State through the Enhanced Nurse Licensure Compact or equivalent clinical degree with current Georgia license
  • Three years of experience in healthcare education or equivalent combination of education, training, and experience
  • NA
  • Knowledge and experience working with Joint Commission and other accreditation and/or other regulatory processes and standards/policies
  • Excellent management, communication, organization, interpersonal, problem-solving, consulting, and team building skills
  • Ability to balance and prioritize multiple projects/tasks
  • Ability to work with a variety of disciplines/departments and employees at all levels
  1. Analyzes and communicates accreditation standards and regulatory rules to ensure optimal compliance with accreditation and regulatory agency requirements.
  2. Monitors hospital and non-hospital locations as indicated or assigned to assure continual survey readiness compliance.
  3. Completes unit tracer reports in a timely manner and communicates results to departmental leader.
  4. Completes monthly, quarterly, and annual reports as assigned.
  5. Coordinates onsite surveys and responses from all regulatory sources in collaboration with Manager, System Regulatory Services.
  6. Identifies improvement opportunities to ensure continuous compliance with the safety, risk, and legal requirements established by accreditation and regulatory agencies.
  7. Collaborates with various disciplines, departments, services, and business partners to assess compliance and develop compliance strategies.
  8. Ensures continuous state of readiness through timely and complete follow-up with the accreditation and regulatory agencies regarding inspections/surveys.
  9. Provides monthly and as-needed reports on readiness status for outside regulatory review.
  10. Educates clinical and non-clinical staff relative to regulatory compliance.
  11. Acts as expert resource for Clinical Practice Council and policy development.
  12. Acts as consultant to Environmental Safety Management Committee, Health Information Oversight Committee, and other committees as assigned.
  13. Acts as consultant for contract and protocol management.
  14. Is responsible for all aspects of managing and leading a team, including interviewing, hiring, training, developing, directing work and processes, managing performance, recognizing, and rewarding employees.
  15. Mentors team members to encourage personal and professional growth.
  16. Encourages ongoing skill development by providing opportunities for continued education.



Safety: Practices proper safety techniques in accordance with hospital and departmental policies and procedures. Responsible for the reporting of employee/patient/visitor injuries or accidents, or other safety issues to the supervisor and in the occurrence notification system.


Compliance: Monitors and ensures compliance with all regulatory requirements, organizational standards, and policies and procedures related to area of responsibility. Identifies potential risk areas within area of responsibility and supports problem resolution process. Maintains records of compliance activities and reports compliance activities to the Compliance Office.


The above statements are intended to describe the general nature and level of work performed by people assigned to this classification.  They are not intended to be an exhaustive list of all job duties performed by the personnel so classified.

Ability to lift up to 15 lbs independently not to exceed 50 lbs without assistance
Bending/Stooping - Occasionally (activity or condition exists up to 1/3 of time)
Climbing - Occasionally (activity or condition exists up to 1/3 of time)
Hearing/Speaking - Effective communication with employees, supervisors/managers and staff. Effective communications with patients and visitors, as required.
Lifting - Occasionally (activity or condition exists up to 1/3 of time)
Pushing/Pulling - Occasionally (activity or condition exists up to 1/3 of time)
Sitting - Constantly (activity or condition exists 2/3 or more of time)
Standing - Occasionally (activity or condition exists up to 1/3 of time)
Walking - Occasionally (activity or condition exists up to 1/3 of time)
Some potential for exposure to blood and body fluids


About Us:

Children’s Healthcare of Atlanta has been 100 percent committed to kids for more than 100 years. A not-for-profit organization, Children’s is dedicated to making kids better today and healthier tomorrow.

With 3 hospitals, 27 neighborhood locations and a total of 638 beds, Children’s is the largest healthcare provider for children in Georgia and one of the largest pediatric clinical care providers in the country. Children’s offers access to more than 70 pediatric specialties and programs and is ranked among the top children’s hospitals in the country by U.S. News & World Report.

Children’s has been ranked on Fortune magazine’s list of “100 Best Companies to Work For” for fourteen consecutive years and named one of the “100 Best Companies” by Working Mother magazine.  We offer a comprehensive compensation and benefit package that supports our mission, vision and values.  We are proud to offer an array of programs and services to our employees that have distinguished us as a best place to work in the country.  Connect to our mission of making kids better today and healthier tomorrow. 

Have questions about the recruitment process?  Check out What to Expect.

Address:  1001 Johnson Ferry Road NE, Atlanta, GA  30342
Function:  Legal/Compliance - Audit/Compliance/Risk

Nearest Major Market: Atlanta

Job Segment: Nursing, Consulting, Manager, Surgery, Registered Nurse, Healthcare, Technology, Management