Clinical Accreditation Coordinator

Position Title Clinical Accreditation Coordinator Bell Hospital Position Summary / Career Interest: The Accreditation Coordinator leads and/or assists the Manager in system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs), including ongoing readiness for accreditation surveys as well as regulatory complaint investigations. The mitigation of regulatory compliance risk will at all times focus on assuring the delivery ofsafe patient care. Responsibilities and Essential Job Functions Assist in assuring accuracy and timeliness in submission to reporting centers ( i.e. Sterling Readiness Rounds) Collects, analyzes and reports data in support of continuous readiness activities Conducts patient and system tracers in patient care areas through observation of practice Disseminates the results of audits and surveillance as needed and as data is available Interpretation of relevance of standards in relation to hospital and clinic policies and practice Maintain databases and sources of information for quality initiatives, accreditation efforts, and regulatory mandates Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements Provide practitioner data for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) to Medical Staff Service as requested Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable) Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department. These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required. Required Education and Experience Bachelors Degree in Health Information Management from an accredited College or University OR Bachelors in Nursing, Respiratory Care or Clinical Laboratory Science High School Graduate Preferred Education and Experience Master's Degree from an accredited College or University Knowledge Requirements Excellent communication, writing, organizational and presentation skills; demonstrates superior oral and written communication and time management skills Advanced working knowledge of computer spreadsheets and databases. Must have strong knowledge base of Microsoft Excel, Word, and prefer experience with data management, ie Microsoft Access. Must be willing to drive to off-site hospital locations. Time Type: Full time Job Requisition ID: R-40111 Important information for you to know as you apply: The health system is an equal employment opportunity employer. Qualified applicants are considered for employment without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, ancestry, age, disability, veteran status, genetic information, or any other legally-protected status. See also Diversity, Equity & Inclusion. The health system provides reasonable accommodations to qualified individuals with disabilities. If you need to request reasonable accommodations for your disability as you navigate the recruitment process, please let our recruiters know by requesting an Accommodation Request form using this link asktalentacquisition@kumc.edu. Employment with the health system is contingent upon, among other things, agreeing to the health-system-dispute-resolution-program.pdf and signing the agreement to the DRP. Need help finding the right job? We can recommend jobs specifically for you! Create a custom Job Alert by selecting criteria that suit your career interests. Notice: If you are a Current Employee or Contract Worker, please log into Workday to search for and apply to jobs using the Career application or by searching "Find Jobs". Your application, if submitted using this portal, cannot be moved forward. About The University of Kansas Health System As part of the region’s premier academic medical center, The University of Kansas Health System in Kansas City is a world-class healthcare provider and destination for complex care and diagnosis. We are driven by our commitment to service, continuous improvement and to the highest degree of excellence. Collaboration between physicians, nurses, researchers, educators and other professionals who share their expertise leads to exciting discoveries and life-changing treatments for the people we serve.