Atlantic Health System

Accreditation Manager

Job Location(s) US-NJ-Pompton Plains
Position Type
01832200- Quality & Patient Safety
Chilton Medical Center


Atlantic Health System is seeking a Full-time Accreditation Manager coordinates ongoing activities to support organizational continual readiness for accreditation and other CMS and State licensure surveys. Serves as the designated facility liaison coordinating communications with Joint Commission Account Representative and Standards Interpretation Group.



Regulatory Compliance: 

  • Establishes and implements systems and processes to ensure ongoing adherence to regulatory standards within assigned medical center including: Coordination of all on-going preparation for the triennial Joint Commission Accreditation survey. Leads Medical Center Regulatory Committee. Maintains knowledge of Joint Commission, NJ Department of Health, State Licensure, and CMS clinical regulatory standards. Leads and coordinates all Joint Commission Medical Center Accreditation surveys.

Process Improvement:

  • Provides, oversight, support and/or consultative services (project design, selection of data require, development of documentation tools, etc.) to quality improvement teams. Collaborates with the medical, nursing, and other clinical leadership at the improvement teams. Collaborates with the medical, nursing and other clinical leadership at the medical center to achieve excellence in metrics used by external rating organizations (CMS, Leapfrog, US News and World Report, Healthgrades, Vizient, etc.) Participates in preparation of disease specific certification programs and similar speciality designation activities.

Patient Safety:

  • Supports the integration of high reliability organization (HRO) principles into the organization and advancement of the organization and system in the HRO journey. Supports initiatives to improve the Culture of Safety including 'Just Culture'. Collaborates with Legal/Risk Management to track and trend adverse events, conduct root cause analysis (RCAs) reviews, ensure the development and timely execution of complete and thorough risk mitigation strategies. Proactiveley identifies opportunities to eliminate risk using Failure Mode Effects Analysis (FMEA) and other proactive risk assessments.

Quality Management:

  • Participates in the development and implementation of policies, programs, and initiatives in order to improve the overall quality of patient care services and ensure compliance with regulatory requirements. Partners with CMOs, CNOs, Department Chairs, Service Line leaders, infection prevention, clinical staff and leadership to develop an efficient, intellectually rigorous, and engaging structure to encourage the alignment of their practice with the quality and safety agenda and regulatory requirements.



  • Proficient in all applications of Microsoft Office
  • Excellent written and verbal communication skills
  • Strong organizational skills and ability to multi-task various responsibilities

Minimum Education:

  • Bachelor's Degree required (Nursing or Health Related Science realted field preferred)


  • Master's Degree in a healthcare related field or MBA preferred


  • Certified Professional in Healthcare Quality or Accreditation preferred but can work towards obtaining certification
  • Current Registered Nurse License (NJ) or Clinical License required

Relevant Experience:

  • 3-5 years experience in quality improvement, patient safety, or accreditation within a healthcare setting preferred
  • 5 years of clinical experiences within an acute care hospital or health system

About Us

Atlantic Health System aims to deliver the highest quality, safety and care combined with the best experience for our patients and their families. We are confident that you will find success within Atlantic Health System, which has been named for the 14th year in a row to Fortune’s “Top 100 Best U.S. Companies to Work For” list. We believe you will find that our culture of collaboration and care exemplifies the value we place on our patients, their families, and our employees.

EEO Statement

Atlantic Health System, 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 status.


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