Sr. Accreditation/Assurance Specialist

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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