Manager, Accreditation Operations

DEPARTMENT

Clinical Affairs

BASIC FUNCTION

Manage the accreditation application lifecycle across ACEP’s six accreditation and recognition programs. Oversee key application workflows and activities, including application review, reviewer coordination, site visits, accreditation decisions, and related follow-up. Supervise the Accreditation Program Specialists and support consistent processes across programs. Lead ongoing quality improvement and workflow enhancements. Serve as the administrator of the consolidated accreditation application platform and work with ACEP IT staff and external vendors on system maintenance, updates, and improvements. Collaborate with Finance and other internal staff on application fees and related processes. Provide timely and responsive support to accreditation applicants. Support the Accreditation Senior Manager and collaborating organizations to ensure success and continuous improvement of ACEP’s accreditation programs

Characteristic Duties and Responsibilities

• Application Operations:

  • Lead the accreditation application lifecycle from intake through decision for all ACEP accreditation and recognition programs.
  • Manage application timelines, assignments, and process status; communicate with applicants throughout the process and escalate issues as appropriate.
  • Establish and monitor workflows, application volume, and timelines for each stage of the accreditation process. Identify and address delays or bottlenecks.
  • Implement process-improvement strategies across accreditation operations.
  • Develop and maintain accreditation operating procedures, guidance, and internal resources to support consistent processes across programs.
  • Utilize project management tools to organize and track applications effectively and create and distribute status and trend reports for internal and external stakeholders.
  • Monitor accreditation volume and financial trends to support budget tracking, forecasting, and program planning.
  • Coordinate and schedule virtual and in-person site visits and required review calls with sites and clinical reviewers.
  • Oversee accreditation decision processing, award and certificate issuance, custom site-improvement letters, and provisional-accreditation tracking.
  • Provide guidance and technical assistance to applicants throughout the accreditation process, including resolving or escalating questions and concerns as appropriate.
  • Oversee operational processes associated with corrective actions/resolutions, renewal/reaccreditation, resubmission, and other post-decision activities.
  • Serve as a liaison with Finance to support accurate tracking and reconciliation of application fees, scholarships, clinical reviewer payments, and other accreditation-related financial activity.

• Accreditation Technology and Platform:

  • Serve as the department lead and business owner for the accreditation application platform, including workflows, user access, data management, and overall system functionality.
  • Partner with ACEP IT staff and external platform vendors to identify system needs, improvements, and modifications and support implementation of updates and enhancements.
  • Triage technical issues experienced by applicants, clinical reviewers, and staff, and coordinate with IT and vendors to support timely resolution.
  • Maintain the accuracy and completeness of application data and records within the platform.
  • Monitor the overall effectiveness and usability of the platform and recommend improvements based on staff, applicant, and clinical reviewer feedback.
  • Review and analyze application data and supporting documentation to identify common challenges, frequently used approaches, and trends across program criteria and support research or information requests based on applicant submissions.

• Clinical Reviewer Management:

  • Manage the clinical reviewer pool and pipeline across accreditation programs to support current and future application review needs, including ongoing reviewer recruitment.
  • Oversee reviewer assignments, availability, workload, and participation to support timely and consistent application reviews.
  • Develop and lead implementation of standardized reviewer onboarding and training across accreditation programs, in collaboration with program leadership and subject matter experts.
  • Develop comprehensive reviewer training resources and tools and serve as the staff lead and key point of contact for clinical reviewers across accreditation programs.
  • Maintain reviewer qualification records, contracts, payments, and conflicts of interest. Monitor reviewer engagement, responsiveness, and completion of assigned reviews, addressing operational issues as needed.

• Supervision and Team Development:

  • Supervise, support, and develop the Accreditation Program Specialists, including assigning work and helping balance responsibilities across accreditation programs.
  • Promote consistent processes and cross-training across the team to ensure continuity and appropriate staff coverage.
  • Review application and decision materials for consistency and accuracy and help resolve issues or escalations as needed.

• Programmatic and Governance Liaison:

  • Ensure program criteria, policies, and requirements applied throughout the accreditation process accurately reflect those approved by the appropriate governing body and are implemented consistently.
  • Maintain regular communication with program leadership and governance bodies, providing updates on application activity, emerging trends, recurring issues, and opportunities to improve the accreditation process.
  • Triage clinical and programmatic questions or challenges raised by applicants and clinical reviewers, directing them to the appropriate program leads, subject matter experts, or governance bodies for guidance and resolution.

• Special Projects:

  • Provide special project support to the supervisor.
  • Serve as a staff liaison for ACEP committees, sections, or other groups/bodies as assigned by the supervisor.
  • Provide support to ACEP grants as assigned by the supervisor.
  • Ensure stakeholder satisfaction and support other projects as assigned by the supervisor.
  • Support the operational development and implementation of new accreditation and recognition programs within ACEP's shared processes and application platform.

Relationships and Contacts

Reports to:

Senior Manager, Accreditation

Supervises:

Accreditation Program Specialists (2)

Internal Contacts:

All staff, including Information Technology, Finance, and Marketing and Communications

External Contacts:

Accreditation and recognition applicants, accredited organizations, ACEP members, emergency department and hospital staff, program clinical reviewers, and staff from other associations and collaborating organizations

Required Education and Experience

• Bachelor's degree in operations, project management, information systems, public health, healthcare, or related field, or equivalent experience.

• Five years of project management or program operations experience, including supervisory experience. Accreditation program knowledge is a plus.

• Demonstrated experience administering a workflow or database system, including configuration and data integrity; experience supporting a system implementation or migration strongly preferred.

• Experience leading and implementing quality and performance improvement initiatives.

• Experience administering an accreditation and/or credentialing program.

• Proven self-management and team-management skills.

• Strong interpersonal and communication skills, with a high level of accuracy and the ability to meet deadlines.

• Supervisory experience.

• Proficiency with web content management systems, Microsoft products, and databases.

• Ability to travel as required; anticipate 1–2 times per year for 2 to 4 days.

Required Education and Experience

• PMP and Quality Improvement certification a plus.

• Experience with accreditation or certification programs.

• Experience implementing and managing technology platforms and membership databases.

• Familiarity with reporting and spreadsheet software.

• Experience in the healthcare field.

We are an equal opportunity and E-Verify employer who offers a competitive salary, an excellent benefits package, a retirement plan, and more.