RN - Clinical Accreditation Specialist - AOMC QMPI

Brief Description

MAIN FUNCTION:

The Clinical Accreditation Specialist acts as a consultant on interpretation of regulatory standards, including The Joint Commission and Centers for Medicare and Medicaid Services (CMS); ensures a constant state of readiness; advises on policy development, educates health care providers on the relevance of standards supporting a culture of safe, high-quality patient care, and contributes leadership and assistance to enterprise-wide initiatives.

Performance Improvement And Compliance

Duties and Responsibilities:

• 1. Assumes the daily organizational responsibility for quality improvement and compliance for the Arnot Health System.
• 2. Directs all organizational continuous accreditation readiness activities.
• 3. Provides consultative services to all levels of the organization on accreditation/regulatory issues, interpretation of standards and policies, and linkage to clinical and operational processes.
• 4. Develops and implements a continuous readiness plan with scheduled activities designed to educate and engage all levels of staff and providers to sustain high performance per internal and external standards.
• 5. Coordinates formal on-site surveys for The Joint Commission and CMS, acting as primary liaison with the surveyor team, including overseeing and coordinating schedule, activities, and remediation of open issues.
• 6. Manages operational aspects of accreditation applications, ongoing standard’s assessments, development of corrective action plans for prioritized risks, and design of audits to evaluate effectiveness of improvements.
• 7. Organizes and delivers education and communication on continuous accreditation standards and readiness at all levels of the organization, including senior leaders, middle managers, physicians, and staff.
• 8. Partners with Safety & Risk Management and Infection Control on sustained compliance with the National Patient Safety Goals and other patient safety standards.
• 9. Partners with Quality Management and Performance Improvement to leverage opportunities to sustain compliance with best practices as part of existing improvement teams within operations.
• 10. Ensures documents required by accreditors/regulators are produced and updated and that those responsible for those documents are fulfilling their responsibilities.
• 11. Provides support and expertise to hospital administration’s policy and procedure committee with scheduled review and update to appropriate policies and access to all relevant parties.
• 12. Performs other related duties and participates in special projects as assigned.
  
  

Other

• 1. Is responsible for attending all annual mandatory educational programs as required by position.
• 2. Understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer to provide a secure and pleasant experience with the Arnot Health.
• 3. It is understood that this lists typical duties for the classification and is not to be considered inclusive of all duties, which may be assigned.
  
  

Education

RN license required. Bachelor’s/master’s degree in healthcare-related field preferred. Certification is preferred – may include CPHA (Certified Specialist in Healthcare Accreditation), CPHQ (Certified Professional in Healthcare Quality), or other certifications relevant to this field.

Experience

• 1. Five (5) years of clinical and/or administrative experience in a healthcare setting, including specific experience related to accreditation and regulatory bodies, such as Joint Commission, CMS, and state licensing agencies required.
• 2. Must have a working knowledge of quality improvement methodologies, tools, and data management skills.
• 3. Leadership and change management skills required. Demonstrated analytical problem-solving skills.
• 4. Effective verbal and written communication skills, including presentation and training capabilities required.
• 5. General understanding of medical terminology and the Electronic Medical Record for the institution is required.
• 6. Ability to perform assignments independently with minimal supervision is required.
• 7. PC-based computer skills, including Microsoft Office required. Needs to be well versed with software for flow diagrams and mapping lean processes.
  
  

Cardiopulmonary Resuscitation (cpr) Requirements

No CPR required.

Physical Demands

Routine office job

Exposure Category

Category III. Tasks that involve no exposure to blood, body fluids, or tissues. And Category I tasks are not a condition of employment.

• A.D.A Essential Functions