RN - Accreditation Manager

  • New Orleans, LA
  • Direct Hire
  • Job ID: FL187-2697575

Title: Accreditation Manager – New Orleans, LA

Schedule: Full time - No weekends

Facility Spotlight:

This medical center has provided the knowledge, expertise and specialized care vital to the healthcare needs of families, women and babies in Jefferson Parish for more than 50 years. Since opening in 1964, our hospital has delivered more than 1000,000 babies and treated well over 300,000 patients. Our initial commitment to treating women and their babies has grown by expanding services and offering a wider range of healthcare options for the entire family. We provide cutting-edge technology in many specialties including obstetrics/gynecology, orthopedics, inpatient rehabilitation, radiology and surgery.

With 235+ beds, this is an acclaimed teaching, research and medical center serving the greater New Orleans area. This facility has been named a World’s Best Hospital by Newsweek in its 2019 listing of the top medical facilities across the globe. Of the 1,000 hospitals listed in the report, this is one of just 250 “World’s Best Hospitals” found in the United States and the only hospital in southern Louisiana on the list.

Accreditation Manager


  • Monitor hospital-wide compliance with regulatory and accrediting agencies (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing) to ensure ongoing survey readiness.
  • Facilitate and coordinate hospital-wide data collection, measurement, trending and dissemination of information regarding regulatory standards and compliance (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).
  • Inform all management levels regarding current developments and changes in regulatory standards (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).
  • Provides regulatory education to new and existing hospital staff and medical staff to achieve and maintain compliance.
  • Assists in facilitating quality improvement teams assuring the implementation of strong quality improvement strategies using proven quality methods, tools/techniques.
  • Initiate, coordinate and support necessary changes or action plans and hospital-wide and department-specific performance improvement projects to support regulatory agency standards.
  • Oversees and directly supervises the activities and functioning of the PI Coordinator and Peer Review including interviewing, coaching, counseling, orientation, training and evaluation within established guidelines.
  • Monitors the day-to-day operations of assigned department staff, reacting effectively and efficiently to unplanned circumstances, demands and challenges facing the department to ensure consistent quality of service.
  • Coordinates other regulatory standards (i.e. Joint Commission, CMS, QRS, CAP, DHH, hospital licensing).initiatives activities as appropriate. 


Bachelor's degree in healthcare related  field 

Master’s degree  preferred.

MUST BE A  RN ( will only consider a Non RN if they extremely strong with Accreditation Experience


2-3 years healthcare experience in Accreditation, performance improvement and JCHAO. 


Healthcare experience should be recent and within a clinical setting

  • Proficiency with performance improvement models, preferably FOCUS-PDCA  Knowledgeable of PI related Joint Commission standards.
  • Participation in previous Joint Commission survey(s) required.  PI related experience required.
  • Proficiency with Microsoft Excel and Access.

MUST have leadership experience

MUST have Healthcare care experience


  • Louisiana State RN license or compact license is accepted 

Additional Information:

  • 3 hospitals in system.  1 with own Leadership team. 
  • They are divided between North Shore & South shore of Lake.  The North shore does not work in lock step with the South.  They have their own anesthesiologist group & surgeons. 
  • South shore (them) more Academic.  Have downtown & Lakeside campuses
  • Reports to Administrative Director of Quality
General Comments

Salary:  Up to $125,000   - Salary is based on experience

Sign on:  $15,000 - Paid in First Paycheck 

Relocation: Yes - Paid in First Paycheck 

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