Job Description
POSITION SUMMARY:
Under the general supervision of the Corporate Director of Compliance, Risk & Quality, the Corporate Accreditation Manager is given the necessary authority and responsibility to oversee, facilitate and perform the necessary tasks to achieve facility regulatory and accreditation goals. The Accreditation Manager also serves as the primary point of contact for scheduled and unannounced onsite surveys, regulatory readiness, audits/ tracers, and associated education surrounding accreditation standards and compliance.
JOB SPECIFIC RESPONSIBILITIES:
Oversees all system-wide accreditation activities and recommends strategies to maintain and improve upon survey outcomes. This position takes the lead on documentation and trending such accreditation activities and communicating to respective leaders in a meaningful and collaborative way.
Serves as the subject matter expert (SME) for DNV, CARF, Joint Commission, and RTC Minimum Standards where appropriate, utilizing clinical and experiential knowledge to enhance effectiveness of NHS programming and policies.
Develop and maintain professional relationships with key opinion leaders and other facility staff in order to establish collaborative lines of communication and partnership in improvement efforts.
Receives assignments and sets work priorities, coordinating accreditation tasks to meet deadlines.
Conducts facility accreditation tracer activities, garnering participation, providing feedback and recommending changes.
Provides and oversees accreditation education to staff where appropriate, including engaging with medical staff for high-quality accreditation activities for staff and healthcare providers.
Plans and prepares audit and tracer initiatives which align with the quarterly or annual goals established by NHS leadership, CMO or Governing Body.
Maintains current knowledge and sources accreditation information from authoritative bodies relevant to local, state, and federal changes to regulatory standards, accreditation or other emerging requirements.
Collaborates with facility Directors and key personnel to ensure elements of corrective action plans or improvement initiatives are on track.
Serves as the SME and consultant across the system pertaining to survey guidance, CAPs and planning.
Drafts written directives or assigns projects to achieve accreditation objectives.
Presents relevant information at facility Quality Councils or other committees as needed.
Attends staff meetings or other facility meetings and represents the Compliance & Quality Department of NHS in a professional manner.
Performs other duties which may be required of the facility or organization from time to time.
POSITION QUALIFICATIONS:
EDUCATION:
Associate degree in Nursing required.
Bachelor's degree in nursing preferred.
Other degrees may be considered on a case-by-case basis.
EXPERIENCE:
Minimum of 3-5 years of recent hospital experience, preferably acute care, long term care, or rehab setting
Demonstrated experience leading an accreditation survey and accreditation activities
Minimum of 1 year experience in a healthcare quality, compliance, or patient safety department is preferred. Alternate experience will be considered on a case-by-case basis.
Experience managing projects involving cross-departmental teams and working in a matrix structure is preferred.
A strong understanding of the principles of a Quality Management System (QMS) is preferred
LICENSURE/CERTIFICATION:
Unencumbered Registered Nurse (R.N.) license in the State of Texas or another compact state is preferred
Basic Life Support (BLS) is required
CPHQ or other equivalent and relevant healthcare certification required, or within 12 months of hire.
KNOWLEDGE, SKILLS and ABILITIES:
Advanced knowledge of MS Outlook and MS Office required
Experience and knowledge navigating and interpreting a medical record
Extensive knowledge of health care standards, including, but not limited to CMS, JC, DNV and CARF
Excellent project management skills, presentations, and use of audit tools and tracers.
Working knowledge of pediatric care, and sub-specialties, such as Prader Willi Syndrome, Autism, and other complex pediatric conditions
Advanced verbal and written communication skills necessary to effectively collaborate in a team environment and make meaningful contributions to projects and assignments
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