Job Description

Plans and facilitates accreditation activities in support of standards and federal, state and local regulations. Ensures regulatory and accreditation activities support the goals of the Institute for Clinical Excellence and Quality (ICEQ) and meet external requirement for continuous accreditation and licensure.

Job Responsibility

• Provides strategic advice and guidance to the Clinical Quality Improvement function. Plans, organizes, and implements accreditation activities and a CSR program for the organization; coordinates activities across the organization to foster continued compliance with accreditation standards and licensure regulations.
• Collaborates with various facilities, service lines to assess compliance and develop compliance improvement strategies and measurement; collaborates with site management on the CSR process and make recommendations for improvement; identifies existing compliance processes that represent "best practices" for use throughout the organization.
• Provides most current accreditation and survey information, site support and consultation before, during and after survey; coordinates and prepare mock surveys and comprehensive survey reports for facilities.
• Tracks, trends and analyzes survey findings to identify areas requiring prioritization / follow-up; prepares summary reports / presentations related to accreditation activities / results.
• Facilitates teams or workgroups to develop processes to meet new or challenging accreditation requirements.
• Provides education centrally as well as on-site consisting of ongoing education related to standards, elements of performance, and scoring, tracer techniques, and relevant focus areas for accrediting agencies.
• Develops and disseminates reference material including newsletters, updates, communications, and memory aids.
• Facilitates / develops policies and procedures that comply with standards and Federal and State regulations and requirements.
• Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.

Job Qualification

• Graduate from an accredited School of Nursing required.
• Current License to practice as a Registered Professional Nurse in New York State required, plus specialized certifications as needed.
• 10 years of relevant experience and 2 years of leadership / management experience, required.

*Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).