Viewing: Director of Compliance and Accreditation Services

Director of Compliance and Accreditation Services

Job: 125953

Location: Bridgewater, MA

Facility: Bridgewater State Hospital

Type: Full-Time

Shift: Day 8 hour

Recruiter: Colleen Norcross


Why Wellpath

Here at Wellpath, everything that we do is about taking care of people – our patients, our staff and our partners. We are committed to making a difference by providing hope and healing to vulnerable patients in challenging clinical environments. Our talented, compassionate team thrives in an autonomous environment, is empowered and supported by education, training and the resources to practice healthcare the way it is meant to be and strives to “Always Do The Right Thing!”




About this role

The Director of Compliance and Accreditation is responsible for the overall coordination of regulatory and quality assurance activities within all disciplines at Bridgewater State Hospital (BSH) to include oversight of compliance with Joint Commission and Department of Corrections standards and regulations.

This position works closely with the Hospital’s Executive Management Group and Director of Performance Improvement to develop and implement a systematic approach to performance standards compliance that encompasses planning, design, deployment, and sustainability of processes and outcome measures. This role also works closely with the Nursing, Medical, and Clinical staff to ensure compliance and oversight of all mandatory policies and practices that align with the Client, Joint Commission and state/federal requirements. The BSH Compliance Director is also responsible for oversight and management of workflows and processes that aid in the aggregation and reporting of data relative to compliance standards linked to all contracted services at BSH. This may include oversight of related duties and responsibilities such as medical records management and HIPPA compliance.

What you bring to the table


  • A Bachelor’s degree required in human services, health care field, management, or related field.
  • Master’s Degree preferred.
  • Years of experience in a like position can substitute for academic preparation on a case by case basis.


  • Three years of experience in a performance improvement, quality assurance, medical records management or contract management related position. 
  • Experience in inpatient psychiatric setting is mandatory. Experience in healthcare, correctional, security, forensic facility or secure setting is preferred. 
  • Demonstrated experience in performing tasks related to process design, management and improvement; systems analysis; data collection, analysis and reporting; and other tasks requiring general management and leadership skills may be substituted on a year for year basis for experience in a direct performance improvement, quality assurance, or contract management position. 
  • Strong and comprehensive knowledge of Joint Commission standards as they as these apply to BSH settings is mandatory. Experience working with MA DOC accreditation or regulatory standards desirable.
  • Excellent written, verbal, and computer skills. Experience with Microsoft Office, especially Excel, required. Experience with data analysis software desirable.


  • Medical Records, Healthcare Compliance or other quality professional certification preferred.

What you will do

  1. Plans, facilitates, and directs facility-wide Compliance audits, data collection, analyses and reports to achieve demonstrated best practice person served care and safety outcomes. 
  2. Assists with the implementation, monitoring and maintenance of the hospital’s standards compliance dashboard, consistent with Joint Commission standards, client and other regulatory requirements.
  3. Collects and submits standards compliance data to the BSH Executive Management Team (EMT) and the Director of Performance Improvement bi-weekly, monthly and quarterly as expected by reporting requirements.
  4. Attends committee meetings and provides analysis of compliance data with recommendations for improvement to staff responsible for these functions.
  5. Serves as the coordinator and point person for all DOC HSD quarterly audit activities.
  6. Serves as the expert and lead for the hospital’s Joint Commission responsibilities and expectations.
  7. The above are a highlight of responsibilities, and not a full list. As assigned, other responsibilities may be performed. 
  8. Provides direct supervision to the Medical Records Department, as assigned.
  9. Assists the Hospital Administrator, as a liaison, where requested.
  10. Must be able to apply principles of critical thinking to a variety of practical and emergent situations and accurately follow standardized procedures that may call for deviations.
  11. Must be able to apply sound judgment beyond a specific set of instructions and apply knowledge to different factual situations.
  12. Must be alert at all times; pay close attention to details.
  13. Must be able to work under stress on a regular or continuous basis.
  14. Perform other duties as assigned.

Wellpath is an EOE/Minorities/Females/Vet/Disability Employer

Our investment in you

  • Medical, Dental and Vision Insurance plan options
  • Time off & leave benefits
  • 401K
  • Tuition Reimbursement
  • Parental benefits
  • Perks and discounts
  • And more available here
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