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. 

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.