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The Director develops, implements, and continuously improves the UNC Health system-wide operating system through which hospitals and other assigned care settings interpret requirements, assess and mitigate compliance risk, maintain continuous readiness, manage surveys and investigations, and implement sustainable corrective action. The Director leads a system accreditation department with authority to deploy team members across entities based on organizational risk, workload, survey activity, and priorities.
Reporting to the HCS Executive Director, Patient Safety & Accreditation, the Director serves as a trusted advisor and coach to executive, clinical, and operational leaders; translates complex requirements into practical UNC Health system-wide standards and systems; and provides timely, independent assessment and escalation of material accreditation and regulatory risk. The Director partners closely with the HCS Director, Patient Safety and leaders in Quality, Risk Management, Legal, Infection Prevention, Nursing, Medical Staff, Facilities, Plant Engineering, Pharmacy, and other functions to integrate regulatory compliance with safe, reliable care.
The Director builds a high-performing, collaborative team and promotes a culture consistent with UNC Health’s mission, values, and standards of conduct.
1. UNC Health system-wide strategy and operating system: Develops and directs the UNC Health system-wide accreditation and regulatory readiness strategy, roadmap, governance, and portfolio of work. Establishes common standards, workflows, roles, tools, reporting, and escalation pathways that enable consistent performance across entities and care settings while allowing appropriate local adaptation. 2.
Continuous readiness and risk management: Designs and oversees a risk-based continuous readiness program, including regulatory surveillance, standards interpretation, self-assessment, tracers and audits, mock surveys, executive readiness reviews, and validation of corrective-action effectiveness and sustainability. Synthesizes findings and trends to identify system vulnerabilities, prioritize interventions, and reduce recurrence. 3.
Executive advising, direction, and governance: Serves as a trusted advisor and coach to entity and system executives, governing bodies, and clinical and operational leaders. Communicates the implications of new or changing requirements; presents readiness, risk, and outcome information; and issues authoritative accreditation guidance and direction within established scope. Escalates significant or unresolved threats through hospital executive leadership and the UNC Health system-wide chain of command when timely action is not taken or risk exceeds local authority or tolerance. 4.
Survey, investigation, and response leadership: Directs the UNC Health system-wide approach to announced and unannounced accreditation, complaint, validation, and regulatory surveys conducted by Joint Commission, DNV, CMS, and state agencies. Establishes command, communication, documentation, and response practices; directs entity liaisons through a UNC Health system-wide protocol; deploys accreditation resources; supports executive leaders during high-risk events; and oversees the quality and timeliness of applications, plans of correction, evidence submissions, and other required responses.
Ensures effective leadership and coordination for every survey event while determining the appropriate level of the Director’s direct participation based on risk, complexity, and organizational need. Provides consultation to leaders responsible for disease-specific certification programs. 5. Standards interpretation and UNC Health system-wide policy alignment: Establishes a reliable, documented process for interpreting federal, state, accreditation, and certification requirements and translating them into consistent UNC Health system-wide guidance.
Partners with Legal, Risk, clinical and operational subject-matter experts, policy owners, and entity leaders to resolve complex or conflicting requirements and align policies, workflows, and controls. 6. Cross-functional integration: Builds effective partnerships across Patient Safety, Quality, Risk Management, Legal, Infection Prevention, Nursing, Medical Staff, Facilities, Plant Engineering, Pharmacy, Emergency Management, Human Resources, Information Services, and other functions.
Integrates accreditation requirements into operational design and improvement work and convenes multidisciplinary leaders to resolve complex, cross-entity compliance risks. 7. Department and resource leadership: Leads a geographically distributed system accreditation department. Defines service expectations and professional practice standards; has authority to allocate and deploy staff across entities based on risk, survey activity, workload, and priorities; establishes clear entity relationships; and monitors service quality, productivity, responsiveness, and outcomes. 8.
Talent development and professional capability: Selects, coaches, mentors, and evaluates accreditation leaders and staff. Builds onboarding, competency assessment, continuing education, cross-training, succession planning, and career development systems that create depth of expertise and a flexible UNC Health system-wide team. Develops accreditation capability among executives, operational leaders, and other partners. 9.
Performance measurement and improvement: Defines and monitors UNC Health system-wide measures of readiness, survey performance, corrective-action completion and sustainability, repeat findings, service effectiveness, and organizational capability. Uses data and improvement methods to evaluate the accreditation program, learn across entities, and improve reliability, efficiency, and outcomes. 10. External representation and environmental surveillance: Directs entity liaisons and organizational interactions with Joint Commission, DNV, CMS, and state regulatory agencies through a UNC Health system-wide protocol.
Maintains current expertise in the regulatory environment, evaluates emerging requirements and trends, develops organizational positions and response strategies, and represents UNC Health in relevant professional forums. 11. Fiscal and administrative stewardship: Owns and manages a UNC Health system-wide accreditation budget including operating and capital plans, accreditation-related fees and resources, and vendor and consulting relationships within assigned authority.
Establishes priorities and adjusts investments to support organizational risk reduction, operational effectiveness, growth, and financial stewardship. 12. Leadership contribution: Participates in Unified Quality and UNC Health leadership teams, councils, and strategic initiatives. Promotes collaboration, shared accountability, psychological safety, and a learning-oriented approach to regulatory compliance and patient safety.
Other Information Education
Bachelor’s degree required. Master’s degree preferred. Licensure/Certification
Certified Professional in Healthcare Quality (CPHQ), Healthcare Accreditation Certification Program (HACP), Certified Joint Commission Professional (CJCP), or comparable accreditation/regulatory credential required within two years of hire. Professional Experience
Seven (7) years of progressively responsible experience in health care accreditation, regulatory compliance, quality, patient safety, risk management, clinical operations, or a closely related field, including at least five (5) years of management or progressively responsible leadership experience. Experience leading accreditation or regulatory work across multiple hospitals, campuses, or care settings and advising senior executive leaders is strongly preferred.
Demonstrated experience leading successful surveys, complex corrective actions, and health system or multi-entity change is required. Knowledge/Skills/and Abilities
- Advanced knowledge of CMS Conditions of Participation, state hospital licensure requirements, and standards and survey processes of applicable accrediting and certifying organizations; ability to interpret complex requirements and translate them into practical operating systems.
- Demonstrated ability to define functional strategy, build enterprise infrastructure, establish governance, lead a complex portfolio, and drive measurable results in ambiguous and changing environments.
- Demonstrated ability to define functional strategy, build health system-level infrastructure, establish governance, lead a complex portfolio, and drive measurable results in ambiguous and changing environments.
- Strong people management capability, including organization design, workforce planning, resource deployment, performance management, mentoring, succession planning, and development of high-performing teams.
- Ability to synthesize complex qualitative and quantitative information, distinguish isolated issues from systemic risk, develop clear recommendations, and communicate concisely to executive and governance audiences.
- Expert facilitation, negotiation, consensus-building, and conflict-resolution skills; ability to lead multidisciplinary groups with differing responsibilities and priorities.
- Knowledge of patient safety, performance improvement, risk management, policy governance, and principles of high reliability; ability to integrate regulatory compliance with safe and effective operations.
- Ability to lead effectively during surveys, investigations, immediate-jeopardy situations, urgent regulatory events, and other high-pressure situations. Ability to travel throughout North Carolina, including with limited notice, to support unannounced surveys and other urgent events; maintains close communication with entity leaders and ensures effective coordination whether leading on site or remotely. Job Details Legal Employer: NCHEALTH Entity: Shared Services Organization Unit: Hospital Quality Management Work Type: Full Time Standard Hours Per Week: 40.00 Work Assignment Type: Onsite Work
Day Job Location of Job: US:NC:Morrisville Exempt From Overtime: Exempt: Yes This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Health Care System, in a department that provides shared services to operations across UNC Health Care; except that, if you are currently a UNCHCS State employee already working in a designated shared services department, you may remain a UNCHCS State employee if selected for this job.
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation. UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities.
Please email applicant.accommodations@unchealth.unc.edu if you need a reasonable accommodation to search and/or to apply for a career opportunity.