Responsible for managing operational activities associated with programs for which The Joint Commission has been granted deeming authority or Medicare recognition. This role supports the implementation and maintenance of external reporting, compliance monitoring, and cross-functional coordination related to Centers for Medicare & Medicaid Services requirements. Serves as a key liaison for deeming-related operations, helping ensure accurate reporting, timely follow-up, effective communication, and alignment with organizational and regulatory expectations.

Principal Duties and Responsibilities

• Serves as the lead for designated deemed programs (acute or non-acute care) and provides support to the corresponding program area as needed to ensure continuity and alignment across services.

• Manages activities associated with the use of accreditation information to meet external reporting requirements, including reporting to the Centers for Medicare & Medicaid Services and State Survey Agencies, ensuring data are collected, accurate, and submitted on time.

• Identifies patterns or trends in reporting inconsistencies or data quality issues and works with appropriate staff to implement improvements, education, or system enhancements.

• Develops, tests, implements, and maintains processes for collection, monitoring, and reporting of required data for deeming and Medicare recognition activities, including
• scheduled survey reports
• validation activities
• Immediate Threat to Life notifications
• adverse accreditation decision reporting, complaint reporting, and other CMS-related reporting requirements.

• Serves as a primary contact for internal and external deeming-related inquiries regarding specific organizations, coordinating research, drafting responses, and escalating high-profile or sensitive issues as needed.

• Coordinates meetings and follow-up activities related to deeming authority, Medicare recognition, CMS communications, and cross-department operational requirements.

• Assists with the preparation, tracking, and maintenance of documentation, responses, and commitments associated with CMS communications and regulatory expectations.

• Coordinates inter-departmental activities associated with maintaining existing deeming authority applications and supporting new or revised applications, including implementation of changes in survey process, reporting requirements, and survey technology.

• Tracks CMS-related projects and operational activities supported by Accreditation and Certification Operations staff and provides updates to leadership as appropriate.

• Assists the CMS Program Director with preparing and providing communication and education related to deeming and Medicare recognition activities to internal and external parties.  Related duties include presenting information in verbal, written, or presentation formats, and providing subject matter expertise in responding to questions stemming from communication and education activities.

• Supports the development and delivery of internal and external communication and education related to deeming and Medicare recognition activities.

• Participates in special projects, continuous improvement efforts, and other duties as assigned.

• Bachelor’s degree in business, healthcare, information management, public health, or a related field, or equivalent work experience.

• 5 years of progressively responsible experience in a healthcare-related field; experience with accreditation, certification, regulatory operations, or compliance activities preferred.

• Experience working across departments and with professional staff, external consultants, external partners, clinical experts, or advisory groups is desirable.

• Strong analytical, organizational, and problem-solving skills, including the ability to manage details, identify issues, and support process improvements.

• Demonstrated experience with reporting processes, data review, and information systems.

• Project management skills with the ability to organize, coordinate, and support cross-functional activities.

• Strong written and verbal communication skills, including the ability to prepare correspondence, explain requirements, and present information to varied audiences.