Trinity Health · 1 day ago
Manager, Performance Excellence and Accreditation
Syracuse, NY
Full-time
Onsite
Mid, Senior Level
$39.45/hr - $59.20/hr
5+ years expTrinity Health is committed to providing compassionate care and improving patient outcomes. The Manager of Performance Excellence and Accreditation will lead efforts in accreditation and regulatory compliance, ensuring quality and safety standards are met across Acute Care services.
DeliveryHealth Care
Responsibilities
Supervises Performance Excellence Consultants who lead or facilitate quality improvement activities, provide project management, data analysis and measurement of outcomes, document and report the results and accomplishments of quality improvement initiatives in concert with other team leaders
Manages and directs the implementation of organizational regulatory compliance activities across all areas of Acute Care Syracuse, partnering with unit and program managers and leaders as appropriate
Leads organization pre-survey activities (preparation of documents for surveyor review while on site)
Coordinates organizational response during CMS, Joint Commission surveys, State Licensing, and third-party on-site surveys
Communicates survey results and assists with development of action plans and survey response in accordance with regulatory timelines
Assures completion and effectiveness of action plan and reports any required measurement in a timely fashion
Manages the daily functions of the Accreditation Software, Joint Commission extranet and CMS Quality Net websites to assure compliance with regulatory reporting requirements
Works with organizational leadership to identify regulatory gaps and works to develop plans to address these gaps and issues
Utilizes performance improvement methodologies and change management strategies to address identified compliance gaps in regulations and standards
Works with organizational leadership to evaluate the effectiveness of regulatory activities
Strategizes with senior leadership to develop organizational response to new regulations and standards with health system leadership
Partners with a variety of departments across the health system to promote standardization and continuity of patient care activities to meet regulatory and patient safety requirements
Works with the Quality Resources staff to develop, design and maintain data trend reports
Verifies accuracy and integrity of data that is publicly reported, prior to publication by external agencies
Develops and oversees a system of ongoing organizational tracers to identify quality, safety, and regulatory issues and assure continual survey readiness
Interacts with external consultants to improve organizational survey readiness
Proactively monitors proposed changes in regulatory requirements, and other external reporting agencies and shares information with applicable staff, leading the development of action plans to assure compliance when proposed changes become effective
Participates in hospital and system quality and safety committees and teams
Serves as a resource/consultant to all departments related to quality, safety, accreditation and regulatory issues
Leads task forces and teams charged with improving regulatory and accreditation compliance
Serves on system-wide committees directly related to regulatory and accreditation requirements
Maintains knowledge of current trends and developments in the fields of accreditation and regulatory standards/compliance
Networks with Trinity System Office and other accreditation professionals. Acts as a liaison to Trinity Health Accreditation Liaison workgroup
Willing to learn new skills and tools necessary to facilitate compliance, quality and safety activities
Maintains good rapport and cooperative relationships. Approaches conflict in a constructive manner. Helps to identify problems, offer solutions, and participate in their resolution
Maintains the confidentiality of information acquired pertaining to patient, physicians and employees. Discuss patient and hospital information only among appropriate personnel in appropriately private places
Behaves in accordance with the Mission, Vision and Core Values of SJH
Assumes responsibilities for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management
Participates actively with leadership in recommending decisions regarding practice issues and material resources
Participates in hospital and medical staff committees and task forces related to quality and cost factors of patient care delivery, quality management or accreditation factors as necessary
Designs, teaches and evaluates education programs for accreditation and regulatory issues as needed
Performs other duties as assigned
Qualification
Required
Bachelor's degree in Nursing, Pharmacy or other clinical or health care systems background with a master's degree in a healthcare or healthcare-related field preferred
Lean training required
Six Sigma training at a green belt or higher preferred
Minimum of two to three years progressively more responsible related work experience in accreditation and regulatory activities
Experience with and understanding of key functions of hospital and medical staff departments or services
Advanced interpersonal skills necessary to effectively communicate complex theoretical and technical concepts effectively with a wide variety of individuals
Advanced analytical and computer skills in order to manage project work and data
Advanced analytical skills necessary to develop sound recommendations and assist in implementing improved delivery of care systems, policies and procedures, evaluating clinical practice outcomes and developing educational programs
Ability to work with and lead multidisciplinary teams in initiatives to facilitate implementation and measurement activities
Ability to integrate information across myriad settings with the goal of standardization (when appropriate), simplification, and reduction of non-value-added work and steps
Preferred
Previous Joint Commission and Centers for Medicaid and Medicare accreditation experience preferred, with a minimum of 5 years of leadership experience within a healthcare delivery system with an in depth understanding of regulatory requirements and healthcare operations
Certification as a Joint Commission Professional (CJCP) preferred
Company
Trinity Health
Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation.
10001+ employees
H1B Sponsorship
Trinity Health has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (9)
2024 (12)
2023 (10)
2022 (9)
2021 (7)
2020 (14)
Funding
Current Stage
Late StageTotal Funding
$0.02MKey Investors
Centers for Disease Control and Prevention
2025-10-17Grant· $0.02M
Leadership Team
Dan Drake
Trinity Health PACE President and CEO
Eileen Coogan
Pres/CEO Allegany Franciscan Ministries
Recent News
Company data provided by crunchbase