Accreditation Specialist

Full-time, 40 hours/week

Monday-Friday 8am-4:30pm

Onsite

Summary

The Accreditation Specialist will support accreditation processes throughout the organization by assisting with continuous readiness for all regulatory inspections/surveys in collaboration with Accreditation Department managers and operational staff in departments/divisions.

Responsibilities

• Become familiar with the location of applicable:
• state and federal standards and regulations
• education and guidance documents
• Develop knowledge of regulatory and accrediting requirements (e.g., TJC, ODH, ODMHAS, CLIA, OSHA, CMS).
• Assist in analysis of compliance with standards/regulations as they relate to varying sets of circumstances and recommend compliance strategies.
• Participate in regulatory surveys.
• Assist in the development of accreditation/regulatory readiness activities throughout the organization, by, at a minimum:
• Acting as liaison between Accreditation Department and organization managers/staff in order to identify compliance challenges/vulnerabilities.
• Participating in and/or lead mock surveys.
• Developing and/or providing education related to the identification of standards and their applicability to areas and/or operations, as well as
  
  

compliance trends/strategies.

• Assisting with workflow, policy and procedure review/revision related to standards compliance.
• Identifying vulnerabilities and providing recommendations for improvement based on analysis of compliance/risk assessments, evidence-based practices, and survey findings.
• Assisting with action planning for standards compliance.
• Demonstrate high level attention to detail.
• Create and deliver PowerPoint presentations and other educational resources focused on regulatory requirements and departmental and organizational compliance.
• Participate in reviewing and updating hospital policies to ensure compliance with regulatory requirements.
• Manage confidential information and/or issues using discretion and judgment.
• Use data tracking, compliance auditing and monitoring tools.
• Assist with development/maintenance of supporting documents for survey.
• Travel to off-site locations to assist with Accreditation Department activities.
• Participate on committees as assigned.
• Other projects/duties as assigned.
  
  

Other Information

Technical Expertise and Skills

• Health care experience is required.
• Excellent interpersonal and communication skills. Ability to effectively collaborate with multiple stakeholders.
• Experience in regulatory compliance/regulatory surveys preferred.
• Experience working with all levels of staff in the organization is preferred.
• Proficiency in MS Office [Outlook, Excel, Word] or similar software is required. Knowledge of clinical documentation systems [EPIC, Midas] is preferred.
  
  

Education And Experience

• Education:
• Bachelor's degree in nursing, active Registered Nurse licensure and BLS certification is required.
• Master's degree is preferred.
• Certification is required within three (3) years of hire: Healthcare Accreditation Certification Program (HACP), Certified Joint Commission Professional (CJCP), or equivalent.
• Years of relevant experience: a minimum of three (3) years in healthcare is preferred.
  
  

Full Time

FTE: 1.000000

Status: Onsite