Accreditation Specialist @ NCH Healthcare System - United States

Accreditation Specialist

NCH Healthcare System
United States
a day ago

Department

18412 - Compliance Risk Management

Schedule

Full-Time

Shift

Day

Hours

primarily days

Weekend

Occasional Weekend Shifts

Job Details

Bachelors Degree Required

The Accreditation Specialist is responsible for accreditation activities to ensure regulatory and hospital licensure compliance throughout the healthcare system. Educates employees, medical and allied health staff, contractors and vendors on accreditation and regulatory requirements, implications for the healthcare environment and strategies to reliably achieve compliance. Identifies opportunities for improvement based on evidence based practices in regulatory and accreditation compliance, analysis of internal and external compliance/risk assessments and findings from regulatory authorities.

ESSENTIAL DUTIES AND RESPONSIBILITIES – Other duties may be assigned.

  • Gathers, synthesizes and analyzes data to evaluate and support ongoing compliance with accrediting and regulatory standards including The Joint Commission, State and Federal regulations, and NCH policies and procedures.
  • Assists in developing, coordinating and implementing activities to assure compliance with accreditation and regulatory requirements.
  • Coordinates and communicates accreditation and regulatory requirement educational offerings across the organization.
  • Prepares status reports, proposals and presentations.
  • Participates in accreditation and regulatory survey visits.
  • Implements process improvement in accreditation and measures outcomes.

  • Maintains collaborative relationship between departments, units, hospitals/healthcare centers and appropriate regulatory agencies.

  • Supports a variety of systems to ensure continual organizational readiness.
  • Participates in tracer activities to ensure ongoing compliance and survey readiness.
  • Supports processes to demonstrate evidence of compliance with standards and improvement plans.
  • Participates in NCH committees such as Environment of Care, Patient Safety, and others as assigned.

EDUCATION, EXPERIENCE AND QUALIFICATIONS

  • Bachelor's degree in healthcare field or quality required
  • Minimum 3 years related work experience
  • Knowledge of quality improvement tools
  • Clinical license, Master's degree and Certified Joint Commission Professional (CJCP) or Healthcare Accreditation Certification Program (HACP) preferred
  • Experience in a clinical healthcare environment with focus on performance improvement, patient safety, risk management or quality management in healthcare preferred
  • Excellent interpersonal skills; ability to work effectively with individuals and/or teams across disciplines
  • Strong analytical, organization and project/process management skills
  • Ability to manage multiple projects simultaneously