Accreditation Specialist

GENERAL SUMMARY:

The Accreditation Specialist oversees all ongoing activities related to regulatory compliance. Serves as a resource/ liaison to provide interpretation, expertise and advice regarding maintenance of standards required by the Joint Commission and other regulatory agencies to administration, medical staff, department directors and Medical Center staff. Provides data to support a culture of excellence and change. Evaluates hospital-wide clinical and patient-related processes; analyzes these processes for clinical effectiveness, patient safety, and efficiency; and makes recommendations for improvements and redesigns that enhance the quality and safety of patient care in the organization

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Serves as primary liaison with regulatory and accreditation bodies such as The Joint Commission & CMS.

3. *Coordinates program-specific certification preparations with Directors and staff responsible.

4. *Meets or exceeds Joint Commission and other regulatory and accreditation standards.

5. Works collaboratively with organizational and external stakeholders to complete licensure applications and maintain accuracy of licenses for the Medical Center.

6. Completes annual organizational and system AHA surveys with support and validation of leaders in the organization.

7. Provides leadership and participates in Medical Center improvement initiatives and teams as assigned.

8. *Provides oversight for the required clinical data retrieval, analysis and submission to external agencies to support quality improvement initiatives and compliance with regulations and standards.

9. *Maintains current knowledge of regulatory and accrediting agencies requirements and ensures that requirements are addressed on an ongoing basis.

10. *Provides direction as needed to ensure policy and procedures systems are administered according to organization standards.

11. *Serves as liaison with all departments for the monitoring, review and analysis of identified clinical quality and process improvement projects.

12. Maintains current knowledge of applicable federal and state accreditation standards, and monitors advancements to ensure organizational adaptation and compliance. Communicates regulatory and accreditation changes as appropriate.

13. Implements the Medical Center Corporate Compliance Plan; assists with review of the Bryan Medical Center's plan for Patient Care Services and recommends adjustments.

14. Assists in the development and implementation of the facility quality and safety plan.

15. *Organizes and serves as the facility host for regulatory and accreditation guests. Develops follow up plans and responses for all regulatory and accreditation findings.

16. *Serves as internal consultant to senior management, medical staff and hospital departments in all matters related to regulatory agency standards and compliance.

17. Reports progress, results or barriers preventing successful implementation of projects to Director.

18. Advances work knowledge by participation in professional development and educational activities.

19. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*").

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of CMS Standards, Joint Commission and other regulatory agencies.

2. Knowledge of the principles of project management and change management.

3. Knowledge of computer hardware equipment and software applications relevant to work functions.

4. Ability to effectively interact and relate to a wide variety of employees, customers and external compliance representatives.

5. Ability to communicate effectively both verbally and in writing.

6. Ability to maintain confidentiality relevant to sensitive information.

7. Ability to lead teams/committees and work as a team member dependent upon role assignment and expectations.

8. Ability to interpret federal, state and local statutes pertaining to healthcare regulatory and accreditation requirements.

9. Knowledge of publicly reported clinical quality and patient safety measures.

10. Knowledge of clinical and patient care-related processes.

11. Knowledge of medical and pharmacological terminology.

12. Knowledge of the principles and theories of process improvement, business management, statistical analysis, budgetary and financial methods and practices.

13. Knowledge of current process improvement methodologies and their application to healthcare.

14. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Degree in Nursing or a healthcare related field and continued professional licensure in a medical or allied health area of study required. Bachelor's degree preferred or a minimum of five (5) years progressive experience in a clinical position required with experience developing and implementing improvement or compliance programs. Master's degree in

Nursing, Health Care Administration or related field desired. Knowledge and experience with systems based analysis and implementations required.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) - Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.