Accreditation Consultant - Full-Time

Location : 1620 W Harrison St, Chicago, Illinois 60612

Business Unit : Rush Medical Center

Hospital : Rush University Medical Center

Department : Accreditation and Regulation

Work Type : Full-Time - 40 Hours per week (1.0 FTE)

Work Schedule : 8-Hour Shifts - Monday to Friday

Rush offers exceptional rewards and benefits learn more at our Rush benefits page ().

Pay Range : $32.00 - $52.08 per hour

Rush salaries are determined by many factors including, but not limited to, education, job-related experience and skills, as well as internal equity and industry specific market data. The pay range for each role reflects Rush's anticipated wage or salary reasonably expected to be offered for the position. Offers may vary depending on the circumstances of each case.

Summary :

Accreditation Consultant I is responsible for supporting Rush in a standardized preparedness approach to continuous survey readiness (CSR) by assessing risk and collaborating with multiple stakeholders, clinical disciplines, RUMC and RUMG staff to improve compliance and alignment with regulatory, accreditation, or certification standards along with organization goals. The focus of this role includes process standardization, assessment, and support in planning, implementation, management of accreditation initiatives and their evaluation. . Additionally, this role supports the Director of Infection Prevention and Accreditation A for promoting a standard and effective approach to ensure that the organization is continually ready for an accreditation survey. .

Other information : Knowledge :

• Bachelor's degree required.
• Working knowledge of CMS Conditions of Participation, State Licensing Code and The Joint Commission standards

Experience and Skills :

Responsibilities :

Principal Duties and Responsibilities :

1. Coordinates and standardizes CSR activities across RUMC and RUMG.

a. Supports the organization and Director in all CSR activities including mock survey, internal tracing, and survey events.

b. Coordinates survey activities including but not limited to planning, logistics, messaging, etc.

c. Coordinates Focused Standards Assessments (FSA) and conduct resolution on open issues

d. Schedules, collects, and analyzes data regulatory rounds at RUMC. Develops, displays, and distributes accreditation and regulatory-focused aids, materials, education, and communications. Maintains all required documentation that will be requested by unannounced TJC surveyors.

2. Analyzes and applies statistical analysis to change process.

a. Submits, aggregates, and analyzes data as identified through CSR activities and create summary documents for sharing this data on a regular basis

b. Creates, maintains, and shares databases to track regulatory trends and compliance

c. Supports the development of measurable end state vision for performance improvement using tools such as statistical significance, operational control limits, etc.

3. Provides project management consultation for key accreditation and regulatory projects by functioning as a performance improvement liaison.

4. Partners with multidisciplinary teams to consult, execute, and drive performance improvement opportunities as they relate to accreditation and regulatory compliance.

a. Serves as liaison with key stakeholders on tasks, deliverables, and issues regarding improvement initiatives.

b. Oversees implementation of compliance strategies identified by project team and ensures successful transition of project to sustain CSR.

c. Creates and monitors dashboards related to improvement activities.

5. Researches TJC standards, CMS Conditions of participation and other relevant regulatory standards and survey processes.

6. Other duties as assigned by Accreditation Manager

Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.

Salary : $32 - $52