Full-time, 40 Hours/Week
Day Shift
Hybrid (Onsite 2-3 Days/Week)
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 conducting 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/opportunities 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.
- 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.