Regulatory And Accreditation Coordinator

Job Description:

The Regulatory and Accreditation Coordinator will be responsible for all aspects of planning and implementation of compliance activities for accreditation and/or regulatory agencies requirements including Joint Commission and CMS. Responsible for development and implementation of educational activities related to accreditation. This includes disseminating interpretations of standards to all appropriate staff with respect to all the organizations functions. Oversees and manages survey readiness methodologies. Assesses monitors and recommends as appropriate activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards. Works with staff from all relevant areas to communicate plan for monitor and evaluate new developments in regulation standards or legislation. Identifies plans educates and assists in implementation of change as required by new/evolving standards. Develops methodologies to support departments in achieving and exceeding continual compliance requirements. Responsible for documentation and other information as requested by regulatory and accrediting bodies including but not limited to submission of applications Focused Standards Assessment (FSA) and action plans in a timely manner. Coordinates site visits follow-up reports compliance activities and historical files. Trains all new management staff on their role in accreditation and survey activities. Serves as a consultant and educator to providers colleagues management and senior leaders related to standards interpretation compliance development of performance measurement systems and improvement programs. Facilitate mock tracer activities and actively round in all departments of the hospital and off-site locations.

Job Requirements:

Education: Bachelors Degree required (healthcare related field preferred)
Experience

• Clinical background preferred
• Minimum of three years of acute hospital experience required
• Healthcare regulatory experience strongly preferred (Knowledge of TJC CMS and DOH regulations/standards)

Required Skills:

• Excellent Communications Skills
• Strong Interpersonal Skills
• Microsoft Word
• Organizational Skills
• Strategic Thinking

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