Job Abstract

Job Description

Plans, organizes, manages and facilitates regulatory & accreditation activities in support of The Joint Commission standards and federal, state and local regulations. Ensures regulatory and accreditation activities support the goals Organization and meet external requirements for continuous accreditation and licensure. Responsible for direction and coordination of Continuous Survey Readiness (CSR) programs and activities in order to achieve compliance with regulatory, licensure and accreditation. Provides consultation and coordination for activities associated with accreditation & regulatory activities.

Job Responsibility

• Responsible for providing strategic advice and guidance to enform system level strategies, as well as planning, organizing and implementing accreditation activities and a CSR program for the Organization.
• Coordinates activities across the organization to foster continued compliance with accreditation standards and licensure regulations.
• Designs an integrated CSR structure that supports a continuous process to improve quality and patient safety throughout the organization.
• Collaborates with various facilities, service lines to assess compliance and develop compliance improvement strategies and measurement.
• Collaborates with leaders/management on the CSR processes and makes recommendations for improvement.
• Identifies existing processes that represent best practices for use throughout the organization.
• Provides most current accreditation and survey information, support and consultation before, during and after survey.
• Coordinates and prepares mock surveys and comprehensive survey reports.
• Tracks, trends and analyzes survey findings to identify areas requiring prioritization / follow-up.
• Prepares summary reports / presentations related to accreditation/regulatory activities and results.
• Leads / facilitates teams or workgroups to develop processes to meet new or challenging accreditation/ regulatory requirements.
• Coordinates The Joint Commission Corporate Orientation.
• Provides education centrally as well as on-site consisting of:
• Ongoing education related to standards, elements of performance, and scoring Tracer techniques
• Relevant focus areas for accrediting agencies
• Develops and disseminates reference material including newsletters, updates, communications and memory aids.
• Facilitates / develops policies and procedures that comply with The Joint Commission standards and Federal and State regulations and requirements.
• Oversees / maintains CSR intranet resources
• Coordinates Performance Measurement activities related to Clinical Contracts.
• Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here but considered related are not essential functions.

Job Qualification

• Masters Degree in Business Administration, Healthcare Administration or related field, required.
• Minimum of 7 years of progressively responsible quality management experience including thorough knowledge of healthcare regulatory and accreditation requirements including, but not limited to, The Joint Commission, Department of Health, and Centers for Medicare & Medicaid Services (CMS), required.