Senior Accreditation Specialist
Company: Parrish Healthcare
Location: Titusville
Posted on: October 19, 2024
Job Description:
Department:
Risk Management/QRM
Schedule/Status:
8am-430pm; Full Time
Standard Hours/Week:
40
General Description:
Under the general supervision of the Quality Manager, the
Accreditation Coordinator is primarily responsible for coordinating
and responding to initiatives related to the accreditation programs
for The Joint Commission (TJC), Agency for Healthcare
Administration (AHCA), the Centers for Medicare and Medicaid
Services (CMS), and other regulatory agencies as appropriate.
Promotes a continuous readiness program that emphasizes quality and
patient safety at the forefront of regulatory compliance.
Collaborates with accreditation and regulatory agencies, system
leaders, content experts, executive sponsors, and medical staff
leaders to develop an effective continuous readiness infrastructure
that ensures the program and organizational goals are sustained
through effective (1) Standard interpretation, (2) Standard
compliance, (3) Education, training, and communication, and 4)
Survey operations. Collaborates with colleagues on a state and
national level to enhance the system's continuous readiness.
Key Responsibilities
Lead continuous readiness efforts
- Proactively coordinates the ongoing evaluation, planning and
support of the continuous readiness infrastructure and processes to
ensure accreditation by deemed status accrediting organizations
such as The Joint Commission as well as other regulatory
accreditation, certifications, and applicable organizational
licenses.
- Support workflow needs and leverage the strengths of content
experts and other accreditation and regulatory leaders to optimize
processes. Collaborates regularly with accreditation and regulatory
specialists to review work plans and progress. Identifies growth
and areas of opportunity to ensure program initiatives are being
met.
- Collaborates with Legal Services, Risk Management, Safety, and
other departments to assure regulatory functions are addressed;
Identifies regulatory vulnerabilities and determines appropriate
corrective action; Partners with regulatory content experts to
identify risk areas and support development, implementation, and
monitoring of regulatory improvement processes.
- Coordinates organization-wide accreditation and regulatory
compliance initiatives; Develops and manages the meetings and
activities of the Accreditation and Regulatory Readiness Committee;
Oversees project prioritization and timeline management of the
Accreditation and Regulatory Program.
- Provides guidance on accrediting and certification standards
interpretation and other regulatory requirements as they apply to
organizational practice; Coordinates resolution initiatives for
accreditation and regulatory compliance initiatives.
Resource development and management
- Develops tool kits, education and reference materials and
provides presentations at leadership meetings; ensures regulatory
resources are up to date, such as links to the CMS CoPs
Interpretive Guidelines and other applicable regulations; and
develops and implements initiatives to evaluate and monitor
compliance with regulatory standards through ongoing organizational
assessment, i.e. Intracycle Monitoring, Focused Standards
Assessment, tracers, mock surveys, and measurement data.
- Coordinates the development and ongoing maintenance of an
organizational communication and education plan for accreditation
through internal communication channels
Collaborates with external partners.
- Serve as an organizational resource and leader in accreditation
and regulation; serves as contact and point person for applicable
standards-related manuals, publications and newsletters and
educational materials; ensures pertinent information is
communicated to appropriate individuals; serves as a resource to
content experts and executive sponsors in standards and CoP
interpretation, insight on upcoming regulatory changes, new
requirements, along with exploring options for operationalizing
requirements; and serves as an expert resource and leader in
regards to deemed status accrediting organization, such as The
Joint Commission accreditation and other regulatory activities and
process.
- Develops, maintains, and implements organizational unannounced
survey plans; coordinates onsite accreditation and regulatory
surveys, including triaging presentation of surveyors, managing
communications, agendas, and logistics for onsite survey
activities; and serves as liaison between onsite surveyors and
organization.
- Provides expertise in the development and implementation of
action plans including measurement support as needed, for required
follow up from the deemed status accrediting organization as well
as other regulatory surveys and Intracycle Monitoring; finalizes
and submits corrective action responses to regulatory agencies for
survey; collaborates with content experts and executive sponsors to
ensure corrective action plans are implemented, measures are in
place and monitored to sustain accreditation.
- Ensures deemed status accrediting organization applications for
accreditation are updated and submitted as required, as accurately
as possible. Performs similar or related duties as assigned.
- Knows fire, disaster and safety procedures and regulations as
it pertains to the work area.
Formal Education:
- Bachelor's Degree in nursing required
Work experience:
- Three (3) years' experience working in the healthcare industry,
healthcare compliance and regulatory activity experience preferred.
Project management experience a plus.
Required Licenses, Certifications, Registrations:
- Current State of Florida RN Licensure required.
- CPHQ, CJCP, or comparable credentialing strongly
preferred.
- Lean Six Sigma Green Belt preferred.
Full Time Benefits:
Eligible to participate in a number of PMC-sponsored benefits,
including:
- Annual Accrual of 152 Personal Leave Bank (PLB) Hours
- Health, Dental and Vision Insurance
- 403(b) Retirement Program
- Tuition Reimbursement/Educational Assistance
- EAP, Flex Spending, Accident, Critical and Other Applicable
Benefits
Parrish Healthcare is a caring community of healthcare
professionals passionate about excellence and fulfilling our
mission of providing Healing Experiences For Everyone All The Time
-.
Parrish Healthcare has a Culture of Choice -. This means a we have
a healing work environment that empowers people to aspire to be
their very best. We partner passionate, talented and skilled people
in the right role with the right resources. We provide a clear and
strategic direction to achieve superior results on behalf of the
communities we serve.
Keywords: Parrish Healthcare, Sanford , Senior Accreditation Specialist, Other , Titusville, Florida
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