Accreditation Coordinator

Under limited direction, plans, organizes and maintains a process to ensure organizational compliance with regulatory standards (DNV and CMS) and continuous survey readiness. Serves as an internal consultant for the interpretation of standards and functional measurement of compliance. Develops performance improvement plans with management/staff on an as needed basis. Interprets new regulations for education purposes and implementation efforts.

General responsibilities include working collaboratively to maintain compliance with accreditation requirements; using data to improve quality of care, including data collection and analysis; coordinating and facilitating meetings; assisting with ongoing collection of information including deficiencies and opportunities for improvement.

Job Specific and Unique Knowledge, Skills and Abilities:

• Excellent verbal and written communication skills; customer service skills; ability to provide presentations to diverse audiences.
• Ability to work collaboratively across department and divisional lines.
• Well organized and detail oriented
• Ability to maintain strict confidentiality of protected health information.
• Ability to prioritize duties and projects; willing to work flexible hours to meet the needs of the department.
• Maintains general knowledge of the ISO 9001 requirements.

Essential Job Functions:

• Serves as an accreditation resource for the organization, to include Medical Staff and Leadership as requested.
• Coordinates the logistics of the accreditation visits, survey activities, and follow up (e.g. DNV annual surveys, state/CMS surveys, complaint and validation surveys.
• Facilitates reporting of accreditation issues to the appropriate leader and follows up on investigation and actions taken to resolve the issue.
• Facilitates investigation and written response for complaints received from accreditation agencies.
• Participates in analysis, development, implementation, and ongoing maintenance of action plans and evaluation of strategic quality or accreditation initiatives.
• Communicates changes of standards/rules/requirements of the accreditation agencies for accreditation/certification purposes to all appropriate parties.
• Contributes expertise to hospital/system and medical staff committees, including meeting coordination and facilitation, as requested.
• Provides educational opportunities and updates for SMH/CVH leadership and staff on accreditation standards and requirements, as requested.
• Completes updates to the accreditation application to meet vendor requirements, including notification of new services.
• Acts as a liaison between chapter owners and the Quality department in the creation of data collection tools; assists owner with analysis of data and identification of opportunities for improvement.
• Facilitates reporting of data and barriers to compliance to the quality oversight committee (QMC)
• Serves as Internal Survey Program Lead and performs internal surveys, based on high risk, high probability to maintain the organization's accreditation status and compliance with ISO 9001 requirements.
• Completes special projects or assignments assigned by the department managers or director.
• Regular and predictable attendance is an essential job function.
• Maintains confidentiality of all hospital and patient information at all times. Follows HIPAA regulations and policies.
• Communicate with patients, families and co-workers in person, in writing and on telephone.

Minimum Qualifications:

• Associate degree: bachelor’s degree preferred.
• 1 year of quality improvement experience required.
• Ability to interact effectively and professionally with patients, hospital personnel, external accrediting team members, and the general public.
• Efficient in computer and relevant software application skills
• Demonstrated knowledge of DNV and CMS Conditions of Participation required and familiarity with other accrediting, licensing, and regulatory standards desirable.
• Evidence of continuing education in standards/regulations/training QI/PI Team member, lead or facilitator 1 - 3 years required.
• Scope: Broad Business unit/multidisciplinary team experience.
• Experience presenting to departmental, product line, and business unit leadership. Knowledge of current healthcare issues and trends.

Joint Position, Full time

CVH is EOE