The Accreditation and Survey Manager is responsible for spearheading all accreditation, regulatory compliance, and quality assurance efforts across the company. This role ensures adherence to standards set by accrediting bodies such as The Joint Commission (TJC), DNV, Quad A, CMS and relevant state and federal regulations. The Accreditation and Survey Manager plays a vital role in driving a culture of continuous improvement and regulatory readiness, while working closely with clinical leadership, hospital partners and internal stakeholders.

Essential Functions

• Lead and coordinate accreditation activities including preparation, documentation, site visit management, and follow-up actions.
• Monitor changes in accreditation standards and healthcare regulations applicable to outpatient rehabilitation and physical therapy services.
• Conduct internal audits, readiness assessments, and mock surveys to identify gaps and ensure ongoing compliance.
• Collaborate with clinic leadership and staff to implement corrective actions and quality improvement initiatives based on audit findings.
• Serve as the point of contact for all accreditation and regulatory agencies during onsite reviews and external audits.
• Develop and maintain policies, procedures, and tracking systems to support accreditation and licensure requirements.
• Provide education and training on regulatory standards and survey preparedness to therapists, clinicians, and administrative staff.
• Support documentation reviews and ensure clinical records meet accreditation and payer standards.
• Prepare and present compliance and quality reports to executive leadership, identifying risk areas and progress on corrective action plans.
• Maintain a central repository of all accreditation-related materials, policies, and correspondence.
• Serve as a liaison for the company with hospital partners and their survey management team.

Required Skills & Abilities

• Proficiency in Microsoft Word, Excel, Window-based applications.
• Excellent communication and relationship-building skills.
• Must have demonstrated skill in prioritizing daily responsibilities and crises to handle a heavy workload.
• Must be able to work successfully in a fast-paced environment.
• Knowledge of federal and state employment laws and regulations

Required Credentials

• Bachelor’s degree in Healthcare Administration, Physical Therapy, or a related field (Master’s degree preferred).
• Minimum of 3 years of experience in healthcare accreditation or compliance, preferably in a rehabilitation or outpatient setting.
• Familiarity with accrediting bodies such as TJC and CMS outpatient therapy regulations.
• Strong knowledge of outpatient clinical operations, documentation standards, and payer requirements.
• Excellent project management, communication, and organizational skills.
• Ability to work collaboratively across clinical and administrative teams.
• Certification in healthcare quality, compliance, or accreditation (e.g., CPHQ, CJCP, CHC) is highly desirable.

Expanding Access to Quality Care

At PT Solutions, we’re more than colleagues; we’re a tight-knit community united in our mission to expand access to quality care. Our commitment to you is evident in our industry-leading professional development opportunities. From ongoing evidence-based clinical education to dedicated mentorship opportunities and an APTA-accredited Orthopaedic Residency Program, we propel our clinicians toward excellence in physical therapy, occupational therapy, speech-language pathology, and athletic training.

As we aim to be the go-to rehabilitation provider, we seek committed professionals eager to join us in that mission. A career with PT Solutions is an opportunity to shape the industry and make a lasting impact. 

Let’s go further together and transform care. Join the #PTSLife today! 

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