What are the responsibilities and job description for the Coordinator Accreditation and Regulatory Affairs position at Mercy Health BSMH?
Provides coordination for accreditation activities for multiple assigned hospitals, sites and/or functions. Works collaboratively with multiple facilities and departments to facilitate systems and/or sub-systems that support accreditation, licensure, regulatory compliance by supporting quality and patient safety. Works with site leaders to coordinate responses to issues related to accreditation compliance. Identifies and coordinates strategies to facilitate identification of compliance opportunities as measured by Joint Commission standards, CMS, state regulations, and other regulatory bodies. Responsible for facilitating implementation of strategies to ensure that the organizations are engaged in an effective, cooperative effort directed at the realization of the identified project scope and objectives.
Travel required as needed to all hospitals in Youngstown and Lorain Markets.
Job Functions
Works with facility leaders to coordinate & facilitate organization-wide preparation strategies and activities to move to a state of continued compliance and survey readiness. In collaboration with Leadership and Quality, contributes to and implements strategy and tactics designed to achieve best in class performance as measured by external standards.
Engages in ongoing assessment and improvement of an accreditation support infrastructure.
Consults on accreditation and safety matters. Facilitates collaboration across functions in relation to improving performance. Advises site teams on viable compliance strategies based on risk stratification.
Communicates regulatory changes, new standards, licensure requirements, compliance strategies, and risk reduction opportunities to facility leaders.
Coordinates key functions and strategies that assess and improve organizational performance as measured by accreditation standards and regulatory requirements.
Facilitates educational sessions that enable leaders, employees, and medical staff(s) to understand standards and justifications for the changes as required by regulatory & accreditation standards. Creates and distributes tools and documents to enable site-based tracers and accreditation compliance surveillance.
Collaborates with site quality, risk, department, and facility leaders on compliance improvement activities.
Provides active support to the site point of contact for regulatory surveys. Provides assistance and direction in survey components including but not limited to document selection, chart identification, staff interview preparation, other risk-mitigation strategies. Communicates with and justifies to surveyors on the organization’s behalf, current practice and processes that demonstrate compliance.
Coordinates and provides direction for responses to regulatory bodies. Participates in the development of post survey and complaint action plans and evidence of standards compliance.
Required: 4 year/ bachelor's degree, nursing or healthcare preferred. 5 years healthcare experiences, foundational working
Preferred: Graduate Degree (Masters), Nursing or healthcare
Many of our opportunities reward* your hard work with:Comprehensive, affordable medical, dental and vision plans
Prescription drug coverage
Flexible spending accounts
Life insurance w/AD&D
Employer contributions to retirement savings plan when eligible
Paid time off
Educational Assistance
And much more
*Benefits offerings vary according to employment status
All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com. If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com
