Job #809 | Accreditation Specialist | Registered Nurse
Plans, coordinates, monitors and improves compliance to and maintenance of Federal, State and Accreditation regulations; manages accreditation activities necessary for attaining and maintaining accreditation and licensure from various organizations, such as Joint Commission (JC), California Department of Public Health (CDPH), CMS, OSHPD, CDPH Lab Field Services, CDPH Radiologic Health Branch, etc.; prioritizes projects, coordinates action plans, and monitors/analyzes results for accreditation projects, consistent with the organization's strategic goals and imperatives.
DUTIES & ESSENTIAL JOB FUNCTIONS:
The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
1. Facilitates and coordinates liaison activities with accreditation and regulatory agencies (i.e. California Department of Health, The Joint Commission, Centers for Medicare & Medicaid Services etc.) including tracking, evaluation and submission of required documentation, survey preparation, arranging on-site visits, required responses, and completion of action items.
2. Assists in all accreditation and regulatory activities, including surveys, survey preparation and readiness assessments.
3. Actively coordinates the organization’s readiness rounds program and is primarily responsible for the development, communication, implementation and tracking of action plans necessary to close identified gaps in care or compliance with The Joint Commission (TJC) standards and Centers for Medicare and Medicaid Services (CMS) and Title 22 regulations.
4. Responsible for reporting unusual occurrence and adverse events to the appropriate
5. Responsible for tracking, reporting, and ensuring the completion of action items resulting from survey findings.
6. Leads and conducts survey preparatory project meetings and project tracking, analysis and identification of deficiencies necessary to correct in order to achieve compliance with standards.
7. Provides education to the organization on regulatory and accreditation issues.
8. Ensures P&P’s are current, evidenced based and meet current standards.
9. Provides oversight of Facility Self Assessment and Intracycle Monitoring activities.
10. Develops comprehensive accreditation work plans by establishing deliverables,
accountabilities, and timelines.
11. Tracks and trends compliance issues.
12. Performs other duties as required.
- Required Education: Bachelor's Degree with a healthcare related focus.
- Preferred Education: Master’s Degree with a healthcare related focus
- Required Experience: Five years health-care related experience.
- Preferred Experience: Familiar with Midas, Epic / Electronic Health Record (EHR), County Health Systems, OSHPD.
- Required Licenses/Certifications: Valid license to practice as a Registered Nurse in the State of California.
- Preferred Licenses/Certifications: Certified in Healthcare Compliance (CHC), Certified
- Professional in Patient Safety (CPPS) or Project Management Professional (PMP) other applicable certifications.
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