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Accreditation Manager, Quality Outcomes - Full Time - Days - Corporate

Atlantic Health System

Newton, NJFull-timeSeen 4w agoSeen in employer's feed 2 days ago

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At a glance

Compensation
No compensation found
Location
Newton, NJ
Schedule
Full-time
Work Authorization
Not specified

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Requirements

Credentials this posting asks for.

NJ RN Or Clinical License, requiredBachelor's degree, required

Job overview

The Accreditation Manager coordinates ongoing readiness for accreditation, CMS, and state licensure surveys, serving as the contact for accreditation issues and guiding departments on regulatory adherence. The role leads Joint Commission medical center surveys, supports quality improvement teams, and collaborates with legal and risk management on adverse-event reviews and mitigation strategies. It also participates in policies and initiatives to improve patient care quality.

Skills & qualifications

RequiredNice to have

Skills

Regulatory Compliance, nice to haveAccreditation Survey Coordination, nice to haveQuality Improvement, nice to havePatient Safety, nice to haveRoot Cause Analysis, nice to haveRisk Mitigation, nice to haveTJC Accreditation, nice to haveCMS Regulations, nice to have

Qualifications

Bachelor's in Nursing, Healthcare, or Related Field, required3+ Years Relevant Experience, requiredNJ RN or Clinical License, requiredMaster's in Healthcare, Business Administration, or Related Field, nice to have5 Years Clinical Experience, nice to haveHealthcare Quality or Accreditation Certification, nice to have

Benefits

Medical Insurance
Dental Insurance
Vision Insurance
401(k) Match
Paid Time Off
Tuition Assistance
Parental Leave

Full job description

Responsible for coordinating ongoing activities to support organizational continual readiness for accreditation and other Centers for Medicare & Medicaid Services (CMS) and state licensure surveys. Acts as point of contact for accreditation related issues. Provides guidance and assists departments to ensure adherence to regulatory requirements.

Principal Accountabilities:

  1. Establishes and implements systems and processes to ensure continuous adherence to regulatory standards within the assigned medical center.

  2. Leads and coordinates all Joint Commission Medical Center Accreditation surveys.

  3. Identifies improvement opportunities and provides support and/or consultative services to quality improvement teams.

  4. Collaborates with legal and risk management teams to track and trend adverse events, conducts root cause analysis (RCAs) reviews, and ensures the development and timely execution of risk mitigation strategies.

  5. Participates in the development and implementation of policies, programs, and initiatives in order to improve the overall quality of patient cares services.

  6. Performs other related duties as assigned.

Required:

  1. Bachelor's degree in Nursing, Healthcare, or related field.

  2. 3-5 years of experience in quality improvement, patient safety, accreditation or relevant area.

  3. Current NJ Registered Nurse Licensure or Clinical Licensure.

Preferred:

  1. Master's degree in Healthcare, Business Administration, or related field.

  2. 5 years of clinical experience within an acute care hospital or health system.

  3. Knowledge of TJC accreditation and CMS regulatory requirements.

  4. Certified Professional in Healthcare Quality or Accreditation.

At Atlantic Health, our promise to our communities is; Anyone who enters one of our facilities will receive the highest quality care delivered at the right time, at the right place, and at the right cost. This commitment is also echoed in the respect, development and opportunities we give to our more than 22,000 team members. Headquarters in Morristown, New Jersey, we are one of the leading non-profit health care systems in the nation. Our facilities and sites of care include:

  • Atlantic Health Morristown Medical Center, Morristown, NJ

  • Atlantic Health Overlook Medical Center, Summit, NJ

  • Atlantic Health Newton Medical Center, Newton, NJ

  • Atlantic Health Chilton Medical Center, Pompton Plains, NJ

  • Atlantic Health Hackettstown Medical Center, Hackettstown, NJ

  • Atlantic Health Goryeb Children's Hospital, Morristown, NJ

  • Atlantic Health CentraState Healthcare System, Freehold, NJ

  • Atlantic Medical Group

  • Atlantic Visiting Nurse

  • Atlantic Mobile Health

  • Atlantic Rehabilitation

We have more than 900 community-based healthcare providers affiliated through Atlantic Medical Group.

We have received awards and recognition for the services we have provided to our patients, team members and communities. Below are just a few of our accolades:

  • Chosen for 17 years by Fortune as one of the magazine’s “100 Best Companies to Work For."

  • Atlantic Health Morristown and Atlantic Health Overlook Named by Newsweek as two of the “World’s Best Hospitals” in 2026.

  • Atlantic Health Morristown and Atlantic Health Overlook ranked within the top three hospitals in New Jersey by U.S. News & World Report’s 2025-2026 Best Hospital rankings.

  • Atlantic Health scored four “A” grades by The Leapfrog Group in its Fall 2025 Hospital Safety Grades, performance measures reflecting errors, accidents, injuries and injections, as well as systems hospitals have in place to prevent harm.

  • Atlantic Health Morristown and Atlantic Health Overlook are New Jersey's only hospitals to be named among America's 50 Best hospitals by Healthgrades in 2026.

  • Named by Becker's Healthcare as one of the "165 Top Places to Work in Healthcare – 2026.

  • Atlantic Health Morristown, Atlantic Health Overlook, Atlantic Health Chilton and Atlantic Health Newton all Forbes Top Hospitals for 2026.

  • Named by Newsweek as one of America’s Greatest Workplaces for Inclusion & Diversity 2025.

  • Atlantic Health rated LEVEL 9 - 2025 CHIME Digital Health Most Wired.

Atlantic Health offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members. Offerings vary based on role level (Team Member, Director, Executive). Below is a general summary, with role-specific enhancements highlighted:

Team Member Benefits

  • Medical, Dental, Vision, Prescription Coverage (22.5 hours per week or above for full-time and part-time team members)

  • Life & AD&D Insurance.

  • Short-Term and Long-Term Disability (with options to supplement)

  • 403(b) Retirement Plan: Employer match, additional non-elective contribution

  • PTO & Paid Sick Leave

  • Tuition Assistance, Advancement & Academic Advising

  • Parental, Adoption, Surrogacy Leave

  • Backup and On-Site Childcare

  • Well-Being Rewards

  • Employee Assistance Program (EAP)

  • Fertility Benefits, Healthy Pregnancy Program

  • Flexible Spending & Commuter Accounts

  • Pet, Home & Auto, Identity Theft and Legal Insurance


Note: In Compliance with the NJ Pay Transparency Act (effective Sunday, June 1, 2025), all job postings will include the hourly wage or salary (or a range), as well as this summary of benefits. Final compensation and benefit eligibility may vary by role and employment status and will be confirmed at the time of offer.

EEO STATEMENT

Atlantic Health, Inc. is an equal employment opportunity employer and federal contractor or subcontractor and therefore abides by applicable laws to protect applicants and employees from discrimination in hiring, promotion, discharge, pay, fringe benefits, job training, classification, referral, and other aspects of employment, on the basis of race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, citizenship status, disability, age, genetics, or veteran

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