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Director-Accreditation
- Mayo Clinic (Rochester, MN)
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Why Mayo Clinic
Mayo Clinic is top-ranked in more specialties than any other care provider according to U.S. News & World Report. As we work together to put the needs of the patient first, we are also dedicated to our employees, investing in competitive compensation and comprehensive benefit plans (https://jobs.mayoclinic.org/benefits/) – to take care of you and your family, now and in the future. And with continuing education and advancement opportunities at every turn, you can build a long, successful career with Mayo Clinic.
Benefits Highlights
+ Medical: Multiple plan options.
+ Dental: Delta Dental or reimbursement account for flexible coverage.
+ Vision: Affordable plan with national network.
+ Pre-Tax Savings: HSA and FSAs for eligible expenses.
+ Retirement: Competitive retirement package to secure your future.
Responsibilities
Position Overview
Mayo Clinic seeks an accomplished, visionary leader to serve as the Director of Accreditation, the enterprise executive responsible for system‑wide oversight of accreditation across hospitals, critical access hospitals, ambulatory and home care settings, behavioral health, disease‑specific certifications, and other programs as assigned. The Director will ensure sustained readiness and exemplary performance against federal and accrediting body requirements, including CMS, HHS, State Departments of Health, The Joint Commission (TJC), and DNV Healthcare—translating complex regulations into clear, reliable practices that create safer systems for patients and elevate care.
Primary Accountabilities
+ Enterprise Strategy & Governance: Set the vision and strategic direction for Mayo Clinic’s Accreditation Program; lead planning, implementation, and evaluation of accreditation and regulatory activities across all sites to maintain accreditation status and CMS certification.
+ Continuous Readiness & Risk Mitigation: Advance proactive tracer methods and readiness practices that integrate survey, tracer, and operational data to identify risk early, reduce harm, and accelerate improvement.
+ Survey Excellence: Direct end‑to‑end survey management, including onsite regulatory surveys and investigations by accrediting, state, and federal agencies; oversee corrective actions and ensure sustained outcomes post‑survey.
+ Modernization & Automation: Champion modernization of accreditation tools and processes—leveraging data, automation, and AI‑enabled regulatory monitoring—to reduce burden, increase reliability, and measurably enhance patient safety.
+ Education & Communication: Lead enterprise interpretation of standards and communicate requirements in accessible, actionable ways; equip leaders and frontline teams with resources that embed accreditation into daily clinical practice.
+ External Representation: Serve as Mayo Clinic’s liaison to accrediting, licensing, and regulatory bodies; provide leadership and advocacy through participation in accrediting body committees and national policy forums.
+ People & Financial Stewardship: Manage accreditation staff across the enterprise and provide financial oversight for the accreditation budget, fostering a high‑performing, mission‑driven team.
Qualifications
+ Master’s degree in business, health care administration, or related field; minimum 10 years of progressive healthcare management or regulatory compliance experience.
+ Clinical degree (e.g., RN, PT, RT) or advanced certifications in compliance/accreditation preferred; CPHQ, CPHRM, or HACP are valued.
+ Demonstrated excellence in written and verbal communication; proven change leadership, strategic planning, and operational execution; high integrity, executive presence, and creativity.
+ Expertise in conflict management; systems thinking; team dynamics; outcomes management; continuous improvement methodologies; and risk assessment/management.
+ Significant experience with Joint Commission standards, CMS Conditions of Participation, and external regulatory requirements.
Leadership Attributes
The successful candidate views accreditation as a catalyst for transformation and measurable improvement in patient outcomes. This leader harmonizes scientific rigor with practical execution—making standards intuitive, embedding reliability into daily workflow, and ensuring that continuous readiness translates into safer care for patients and teams alike.
The Value of this Role
Mayo Clinic’s Accreditation Program is recognized as best‑in‑class, with standardized proactive readiness strategies, tools, and resources that enable clinicians to focus on delivering safe, exceptional care while maintaining an unwavering compliant posture. The Director will elevate this foundation—linking standards to safety, modernization, and enterprise value.
Qualifications
Master's degree in business, health care administration, or related field and 10 years' progressive healthcare management or regulatory compliance experience required. Juris Doctor degree or advanced certifications in compliance or accreditation preferred. Excellent written and verbal communication skills. Change management, leadership, strategic planning and operational skills required. High level of professional integrity, executive presence and creativity required. Expertise at dealing with difficult situations and conflict management. Demonstrated expertise and skill in systems thinking and team dynamics, outcomes management, quality/continuous improvement philosophies and methodologies, and risk assessment and management. Must have significant experience and understanding of The Joint Commission, Centers for Medicare and Medicaid Services Conditions of Participation and other external regulatory requirements. Ability to translate complex regulations into meaningful expectations that are readily communicated across the organization at all levels; supports flexible solutions to ensure regulatory compliance and balance practice innovation. Manages resources effectively and plans for resources needed to support prioritized programs. Licensure/Certification Required: CPHQ, CPHRM or HACP preferred.
Exemption Status
Exempt
Compensation Detail
$155,833.60 - $233,771.20 / year
Benefits Eligible
Yes
Schedule
Full Time
Hours/Pay Period
80
Schedule Details
Monday - Friday, 8am - 5pm
Weekend Schedule
As needed
International Assignment
No
Site Description
Just as our reputation has spread beyond our Minnesota roots, so have our locations. Today, our employees are located at our three major campuses in Phoenix/Scottsdale, Arizona, Jacksonville, Florida, Rochester, Minnesota, and at Mayo Clinic Health System campuses throughout Midwestern communities, and at our international locations. Each Mayo Clinic location is a special place where our employees thrive in both their work and personal lives. Learn more about what each unique Mayo Clinic campus has to offer, and where your best fit is. (https://jobs.mayoclinic.org/alllocations)
Equal Opportunity
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, national origin, protected veteran status or disability status. Learn more about the "EOE is the Law" (https://www.eeoc.gov/poster) . Mayo Clinic participates in E-Verify (https://www.e-verify.gov/sites/default/files/everify/posters/EVerifyParticipationPoster.pdf) and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization.
Recruiter
Ted Keefe
Equal opportunity
As an Affirmative Action and Equal Opportunity Employer Mayo Clinic is committed to creating an inclusive environment that values the diversity of its employees and does not discriminate against any employee or candidate. Women, minorities, veterans, people from the LGBTQ communities and people with disabilities are strongly encouraged to apply to join our teams. Reasonable accommodations to access job openings or to apply for a job are available.
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