Administrative Assistant - Accreditation and Quality Management

Job Description

Assists the Accreditation Specialist (AS) and Quality Management (QM) Manager with all regulatory agency standards, post organization survey or audit activities. Performs Physical Environment Rounding Audits/Reporting with no supervision. Functions as a Global Document Control Administrator (DCA) for PolicyTech, Vizient Clinical Data Base (CDB) co-administrator, and Minitab software user. Will assist with quality metric database entries and data analysis as directed. Able to make independent decisions in judgment according to established hospital policies and procedures. Responsible for solving practical problems, dealing with a variety of issues and interpreting a variety of instructions furnished in written or oral form. Presents a helpful, courteous, and positive attitude when greeting people entering the office or on the telephone. Performs general office duties such as ordering supplies, maintaining records management systems, etc. Prepares reports and general correspondence. Demonstrates understanding and knowledge of the use of computers and office machines in a business environment. Must have the ability to communicate effectively, orally and in writing, with other members of the health care team, representatives of external regulatory agencies and clients. Responsibilities include taking and transcribing committee meeting minutes; assembling, copying and distributing committee packets; management of various databases and providing general clerical support for the Accreditation Specialist and will serve as a back-up for other QM committees as needed.

SHIFT AND SCHEDULE

Full Time: 8:00 AM – 5:00 PM

ESSENTIAL FUNCTIONS/PERFORMANCE EXPECTATIONS

• Demonstrates proficient working knowledge of computer software programs databases, data analysis systems, microcomputer spreadsheet and graphics software, web-based programs/navigation. Able to use computer software applications, such as MS Office suite programs, ProClick, and CaterTrax.
• Able to function as
  • Global DCA for PolicyTech. Associated tasks include development and maintenance of templates, user groups, software troubleshooting, and general assistance to end users.
  • Vizient CDB co-administrator and Minitab user.
• Performs required duties for Document Control Committee (DCC), including the creation and maintaining of required reports, committee packets and meeting communications. In the AS’s absence can run the monthly DCC meeting.
• Responsible for taking and transcribing committee meeting minutes; assembling, copying and distributing committee packets for the AS and will serve as a back-up for other QM committees as needed.
• Provides AS and QM Manager support by conducting research, preparing statistical reports in Mini tab for Committees, RCA tracking and logging for committees, CDB coadmin, handling information requests, and performing clerical functions such as preparing correspondence, receiving visitors, arranging conference calls, scheduling committee meetings and maintaining Accreditation and Quality Management records.
• Assists in the creation and distribution of employee education programs related to Accreditation Standards, Quality Management System (QMS) and associated initiatives.
• Able to function as Physical Environment (PE) Audit Team Leader: performs inspections, data entry, and appropriate work order submission for PE Safety Audits with no supervision.
• Disseminates internal audit communications in required timeframes. This communication includes:
  • Initial Audit report communications to Directors/Designees
  • Audit reminders to Directors/Designees and appropriate Vice Presidents/CEO
  • Monthly requests for monitoring data as needed
• Maintains all DNV Survey binders
  • Documents for Surveyors Binders
  • Corrective Action Plan Evidence Binders
  • Internal Audit Binders
    • PE Audit Binders
    • Quality Audit Binders
• Reads and analyzes incoming memos, submissions, and reports in order to determine their significance and plan their distribution.
• Must have excellent verbal and written communication skills as well as excellent interpersonal skills.
• Must demonstrate and portray an image that positively represents the hospital and the hospital’s core values.

EDUCATION AND EXPERIENCE

• Must be a high school graduate or equivalent. College work is preferred.
• Healthcare Accreditation Certified Professional (HACP)
• Working knowledge of computer software programs such as Microsoft Office
• Language skills:
  • Requires the ability to read and analyze information.
  • Requires the ability to effectively communicate information and respond to questions from all Hospital’s publics.

PHYSICAL REQUIREMENTS

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The individual must be able to:

• Stand, walk, sit, stoop, reach, lift, see, speak and hear. Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non-clinical staff. The individual must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits.