Description

Job Summary

Maintain the system on continual survey readiness for all entities. Collaborates with leaders for developing, implementing, maintaining, and enhancing mechanisms to track, trend, and report accreditation & regulatory compliance measures and reports to the NCHS. Assist and/or lead in the preparation, coordination, and execution of efforts related to major accreditations or equivalent national accreditation entities and other regulatory & governmental agency surveys. Maintains expert knowledge of Federal, States, and Accreditation standards and updates to standards and regulatory requirements through analysis, documentation, reporting of data, and summarizing.

Job Specific Duties

•  Serves as a expert resource for interpretation of state, regulatory, accreditation, and disease-specific care certification standards (as applicable) in relation to system wide policies and practices.
•  Performs routine ISO internal audit tracers, through interviews, document review, and survey assessments to assist in determining compliance with accreditation and regulatory standards and requirements within clinical and non-clinical departments in the hospital, Outpatient Care Centers, and any additional healthcare settings.
•  Collects, analyzes, trends, and reports data in support of continuous survey readiness activities and efforts. Standardizes reports for Accreditation and Regulatory department.
•  Identifies and evaluates the organization's risk areas and provides key input in the development of the annual risk-based ISO internal audit plan.
• Maintain centralized databases and sources of information for Accreditation & Regulatory continuous survey readiness program.
•  Interprets, analyzes, and disseminates the results of ISO internal monitoring tools and surveillance results in a timely manner.
•  Assists in assuring accuracy and timeliness in submission to all accreditation and regulatory reporting requirements.
•  Participates in department and system wide initiatives by compiling and analyzing data, including comparison of outcome measures to benchmark, identify trends, and complete gap analysis.
•  Assists in the identification of activities to reach performance goal and metric set forth by the Accreditation & Regulatory Department.
•  Actively participates in system wide or department specific preparation for accreditation and regulatory audits/surveys by creating and maintaining compliance roadmaps.
•  Provides or assists in providing training, coaching, and guidance to NCHS staff in conducting accreditation readiness and ISO internal monitoring activities.
  

Qualifications

Minimum Job Requirements

• Bachelor's Degree in Business, Healthcare or related field
  HACP certification
• 3-5 years Experience with at least three major hospital accreditation surveys or equivalent, in addition to state and other regulatory agencies - served in the capacity as the lead, coordinator, command center, scribe, and/or escort
• 4-7 years Experience in healthcare/hospital setting
• 2-4 years Experience involving accreditations & regulatory compliance preparation and CMS Conditions of Participation standards
• Less than 2 years Experience in the interpretation & applicability of National Accrediting Standards, Agency for Healthcare Administration (Hospital & Life Safety), Centers for Medicare and Medicaid Services Conditions of Participation, and any other regulatory agencies in a hospital and/or ambulatory health care setting

Knowledge, Skills, and Abilities

• Master's degree preferred.
• Certification in Accreditation, Quality, and/or Project Manager preferred.
• Quality review, analysis, and reporting, as well as, quality background preferred.
• Previous experience in regulatory compliance and/or quality improvement preferred.
• Experience in formal/informal development of educational programs, policies & procedures, plans, and project management preferred.
• Exceptional attention to detail and presentation skills.
• Excellent verbal, written, and interpersonal communication skills and time management.
• Ability to analyze data and regulatory requirements.
• High degree of professional judgment, flexibility, and professionalism.
• Demonstration in the understanding and applicability of organizational behavior, independent, and creative problem solving to handle complex time sensitive projects.
• Ability to meet constant deadlines.
  
  

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