Accreditation & Regulatory Project Coordinator: FT Salaried

Position Highlights:

• Work/life: You will find support to help you manage your personal life while building a career.
• Employee-centric: Tuition reimbursement, loan forgiveness, comprehensive major medical, dental and vision insurance, paid time off, 401(k), health and wellness offerings, monthly employee events, and more. 
• Lifestyle: Sandusky was voted “Best Coastal Small Town in America”. You will have the opportunity to enjoy living and working in this growing area along the beautiful shores of Lake Erie.

About Firelands Health:

Our goal at Firelands Health is to be the best & preferred independent healthcare employer for the Sandusky Bay region.

Firelands Health is the area’s largest and most comprehensive resource for quality medical care. We are “big enough to care for you, and small enough to care about you”. We are locally managed and governed as a not-for-profit healthcare facility, serving the counties of Erie, Ottawa, Sandusky, and Huron, covering a regional service area with over 300,000 residents. Our mission is to provide excellent healthcare, promote community wellness, and improve the lives we serve.

Our Core ACE Values:  Attitude: We choose to be positive and inclusive every day. Commitment: We are committed to exceed the expectations of those we serve. Enthusiasm: We will work passionately to make a difference.

What You Will Do:

• Plans, implements, and coordinates organization-wide activities to assure compliance with accreditation standards, hospital licensure, CMS Conditions of Participation (CoP), and State and Federal initiatives. Assists the team with processes for self-assessment.  Maintains a current and expert level of knowledge regarding accreditation standards, licensure regulations, and conditions of participation for governmental and private payer programs.
• This role will work with a variety of departments and disciplines throughout the health system. This ideal candidate will be organized, detailed oriented, open to learning, and the ideas of others, in addition, have the ability to design structure and processes that support accreditation and licensure compliance. Management of special initiatives/projects can be expected. The ideal candidate will be creative, innovative, and enjoy tackling challenges.
• Serves as a primary resource for accreditation and regulatory standards, as well as, CMS CoPs and initiatives.
• Develops and implements systematic processes for self-assessment enabling identification of gaps in compliance leading to the implementation of corrective actions.
• Reviews processes and policy guidance, ensuring alignment with standards, regulations, and other initiatives.
• Coordinates with Clinical Leaders, Safety and Security, Plant Engineering, the Senior Management Team, and others as needed to test and refine new and ongoing accreditation/licensure concepts and effect positive change.
• Coordinates surveys and data submission for accreditation, regulatory, and payer entities.
• Demonstrates creativity and flexibility in applying accreditation, regulatory standards, standards of practice, and evidence-based practices to enhance patient services and maintain positive professional working relationships with all team members.
• Monitors accreditation standards and conditions of participation and catalogs data documenting evidence of compliance. Coordinates action to ensure standards are enforced.
• Develops and conducts continuing education to support survey readiness.
• Prepares and presents reports as assigned for the Board, Medical Staff, Management Team, and external agencies.
• Assist others with survey activities from preparation through the plan of correction as needed, i.e. ODH (Maternity, Dialysis, Cardiac Cath Lab), disease specific accreditation/certification (Stroke, Joint Replacement, Chest Pain), and service specific accreditation/certification (Commission on Cancer, American Academy of Sleep Lab, College of American Pathologists). This list is not all inclusive, but provides examples.  
• Exercises creativity, ingenuity, judgment, and problem-solving techniques in the absence of established guidelines and precedents and consistently demonstrates an ability to assess a situation from a variety of perspectives, consider several alternatives, and chooses an appropriate course of action.
• Assists and acts as a resource to assigned committees and provides education and training for the organization at all levels.
• Demonstrates responsibility through responsiveness to others and competent follow-up on matters requiring additional attention; contacts appropriate personnel as required, following appropriate channels of communication.

What You Will Need:

• Healthcare related background, with a working knowledge of the hospital environment. Must maintain required licensure, registration, or certifications as per discipline.
• At minimum, Bachelor’s degree in healthcare-related field required.
• Minimum of five years experience in healthcare accreditation, operation, or clinical practice required.
• Demonstrated knowledge of accrediting agency and NFPA Life Safety Codes.
• Ability to present information to all organizational levels.
• Ability to perform arithmetic functions and statistical analysis.
• Ability to utilize personal computer and various software applications for the management of information.

Ability to work in a safe and efficient manner and maintain an accident free work place, including ability to demonstrate a working knowledge of Medical Center emergency codes.

Ability to comply with OSHA regulations and CDC standard and transmission-based precaution recommendations and to utilize proper personal protective equipment.  Ability to comply with provisions of applicable MSDS forms.

Successful completion of the one hundred eighty (180) day get-acquainted period.