Accreditation/Regulatory Specialist Senior

Job ID

68593

Location

Aurora, Colorado

Full/Part Time

Full-Time

Regular/Temporary

Regular

Why Work at Children's....

Here, it’s different. Come join us.

Children's Hospital Colorado has defined and delivered pediatric healthcare excellence for more than 100 years.

Here, the nation’s brightest nurses, physicians, scientists, researchers, therapists and care providers are creating the future of child health. With an optimist’s outlook, a trailblazing spirit and a celebrated history, we’re making new strides every day.

We’ve been Magnet-designated four times by the American Nurses Credentialing Center and are consistently recognized among the nation’s top 10 pediatric hospitals by U.S. News & World Report. 

As a national leader in pediatric care, we serve children and families from all over the nation. Our System of Care includes four pediatric hospitals, 12 specialty care centers, 400 outreach clinics and 7,000 healthcare professionals representing the full spectrum of pediatric care specialties.

We need your expertise.

A career at Children's Colorado will challenge you, inspire you, and motivate you to make a difference in the life of a child. Here, it’s different. Do you have what it takes?

Additional Information

Department: Accreditation

Hours per week: 40, eligible for benefits

Shift: 7-3:30 or 7:30-4:00 M-F

Job Overview

The Senior Accreditation Specialist ensures continuous regulatory compliance within licensed/accredited facilities. They consult and assist in the development, implementation and measurement of complex cross-functional performance assessment and improvement projects/initiatives for hospital licensure and accreditation. They assure accreditation participation requirements for licensed/accredited facilities for The Joint Commission, CMS, state agencies and other regulatory agencies. They conduct ongoing performance analysis to identify clinical outcomes and other improvement opportunities, coaches/educates providers and management and supports teams’/task forces to ensure successful outcomes of projects. They build and maintain strong business relationships with leadership, agency personnel, providers, and employees’ system-wide to facilitate the overall accreditation and regulatory compliance strategies. In addition, the Senior Specialist mentors, coaches, and collaborates with management to direct and coordinate team members. 

Responsibilities

POPULATION SPECIFIC CARE

No direct patient care.

ESSENTIAL FUNCTIONS

An employee in this position may be called upon to do any or all of the following essential functions. These examples do not include all of the functions which the employee may be expected to perform.

Performs all the accreditation and regulatory activities including, but not limited to, survey preparation and readiness assessments, surveys & inspections, post survey audits, documentation and implementation of plans of correction.

Leads organizations readiness tracer program and is responsible for communication, tracking and validation of implementation on action plans in compliance to the regulations

Leads, facilitates, coordinates data collection of organizational compliance with the standards and regulations. Utilizing and collaborates on ongoing improvement in audit tools and methods to assess and support patient care quality improvement projects through data analysis and innovative interventions, in order to improve outcomes for patients and families and to meet accreditation and regulatory requirements.

Effectively assesses organizational needs, objectives and challenges and formulates appropriate improvement strategies in collaboration with assigned areas to support internal clients in achieving regulatory compliance that are aligned with organizational strategy, pillar goals, mission, vision and values.

Develops data collection plans; conducts measurement system analysis and analyzing, interpreting and summarizing data sets to support root cause analysis and to demonstrate improvement.  Establishes appropriate control plans; analysis of existing policies, procedures and practices.  Explores possible alternatives or solutions.

Leads, facilitates, coordinates and provides project management as identified through regulatory compliance processes.  Acts as a team leader and role model to other team members including coaching, training, monitoring, assisting with goal setting and managing the flow of day-to-day operations.

Demonstrates an understanding and ability to interpret the regulations, accreditation standards and organization policies, and how they apply to practice. Collaborates on the review and modification of policies and procedures as applicable to support regulatory adherence

Leads, or co-chairs organization committees. Develops and communicates regulatory information through direct communication, meetings/committees, orientation, and other regulatory training.

Maintains positive working relationships with supervisors, employees, and other stakeholders to obtain cooperation and support in assigned projects or studies.

Mentors, coaches, orients, and collaborates with new team members.

Performs other related duties as assigned.

Other Information

SCOPE AND LEVEL

GUIDELINES: Fully qualified, full performance or journey level. Guidelines are generally but not always clearly applicable, requiring the employee to exercise judgment in selecting the most pertinent guideline, interpret precedents, adapt standard practices to differing situations, and recommend alternative actions in situations without precedent.

COMPLEXITY: Duties assigned are generally complex and may be of substantial intricacy. Work assignment is performed within an established framework under general instructions but requires simultaneous coordination of assigned functions or projects in various stages of completion.

DECISION MAKING: Exercises judgment and discretion, and is responsible for determining the time, place and sequence of the work performed.

COMMUNICATIONS: Contacts with the patients, families, or employees where explanatory or interpretive information is exchanged, defended, and gathered and discretion and judgment are required within the parameters of the job function.

SUPERVISION RECEIVED: Performs work with minimal supervisory oversight. Under general supervision, the employee receives assignments and is expected to carry them through to completion with substantial independence. Work is reviewed for adherence to instructions, accuracy, completeness, and conformance to standard practice or precedent. Recurring work clearly covered by guidelines may or may not be reviewed.

Qualifications

EDUCATION - Bachelor’s degree in nursing or other allied healthcare a related field.  Master’s in health care related field preferred.

EXPERIENCE –Five years of professional experience in nursing, clinical health care, management, quality improvement, and operational analysis work.  A minimum of 2 years of professional experience in healthcare accreditation.

CERTIFICATION(S) – Preferred in related field

Physical Requirements

Ability to Perform Essential Functions of the Job

Audio-Visual: Far Vision: Fair

Audio-Visual: Hearing: Good

Audio-Visual: Near Vision: Good

Work Environment

Exposure: Exposure to blood/body fluid: Regular/Frequent.

Exposure: Exposure to cold/heat: Occasional.

Exposure: Exposure to dampness: Occasional.

Exposure: Exposure to infectious diseases: Occasional.

Exposure: Exposure to noise/vibration: Occasional.

Mental and Emotional Requirements: Independent discretion/decision making.

Mental and Emotional Requirements: Makes decisions under pressure.

Mental and Emotional Requirements: Manages stress appropriately.

Mental and Emotional Requirements: Works with others effectively.

Equal Employment Opportunity

It is our intention that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. We do not discriminate on the basis of race, color, religion, national origin, sex, age, disability, or any other status protected by law or regulation.  Be aware that none of the questions are intended to imply illegal preferences or discrimination based on non-job-related information.

Salary Information

Annual Salary Range (Based on 40 hours worked per week): $70,917.15 to $106,375.72

Hourly Salary Range: $34.09 to $51.14

Benefits Information

As a Children’s Hospital Colorado team member, you will receive a competitive pay and benefits package designed to take care of your needs that includes base pay, incentives, paid time off, medical/dental/vision insurance, company provided life and disability insurance, 403b employer match (retirement savings), and a robust wellness program.

Salary : $34 - $51