Sr. Accreditation/Assurance Specialist

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 organizations 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.
  

Minimum Job Requirements

• Bachelors 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

• Masters 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.