What are the responsibilities and job description for the Clinical Accreditation Specialist position at KINETIX?
We're searching for a Clinical Accreditation Specialist, someone who works well in a fast-paced setting. In this position you will act as a consultant on interpretation of regulatory standards, including The Joint Commission and Centers for Medicare and Medicaid Services (CMS); ensure a constant state of readiness; advises on policy development, educate health care providers on the relevance of standards supporting a culture of safe, high-quality patient care, and contribute leadership and assistance to enterprise-wide initiatives.
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Job Duties & Responsibilities
- Assumes the daily organizational responsibility for quality improvement and compliance for the Hospital System.
- Directs all organizational continuous accreditation readiness activities.
- 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.
- 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.
- Coordinates formal on-site surveys for The Joint Commission and CMS, acting as primary liaison with the surveyor team, including overseeing and coordinating schedules, activities, and remediation of open issues.
- Manages operational aspects of accreditation applications, ongoing standard assessments, development of corrective action plans for prioritized risks, and design of audits to evaluate the effectiveness of improvements.
- 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.
- Partners with Safety & Risk Management and Infection Control on sustained compliance with the National Patient Safety Goals and other patient safety standards.
- Partner with quality management and performance improvement to leverage opportunities to sustain compliance with best practices as part of existing improvement teams within operations.
- Ensures documents required by accreditors / regulators are produced and updated and that those responsible for those documents are fulfilling their responsibilities.
- 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.
- Performs other related duties and participates in special projects as assigned.
Skills & Requirements
