Accreditation Specialist

Responsibilities

• Serves as the organizational expert for DNV, ISO 9001, State and CMS CoP regulations.
• Leads a coordinated response to announced and unannounced external accrediting or regulatory agency visits such as CMS, DNV, CARF, or DHHS.
• Analyzes reports and data such as regulatory surveys and investigations; facilitates corrective action plans (CAP) and plans of correction (PoC) with managers/directors.
• Researches and analyzes DNV, ISO 9001, State, CMS Conditions of Participation (CoPs), and other regulatory agency requirements and standards.
• Responsible for the interpretation and communication of regulatory requirements throughout the organization.
• Stays current with new standards and can present to large groups, teams, or Senior Leadership.
• Provides education, training, and consultation to administrative and clinical leadership, staff, and faculty throughout the organization regarding the requirements of accreditation and regulatory organizations.
• Provides guidance and assistance to service lines, departments, and units regarding improvements needed to monitor and ensure compliance with regulations and standards.
• Provides timely communication regarding new and revised federal, state, and local regulations, standards, and interpretations to administrative and clinical leadership, staff, and faculty.
• Facilitates the development of tools, policies, procedures, and learning aids to promote compliance with standards.
• Builds effective, supportive, productive relationships with leadership, staff, and faculty.
• Manage documented information for hospitals and clinics documents and policies.
• Facilitates quality improvement activities as directed.
• Active participant in the Internal Audit Program and collaborates with operational managers and directors.
• Participates in patient safety improvement work or teams as directed.

Requirements

• Bachelor's degree required in a health care related fields such as nursing, laboratory, public health, healthcare administration or other fields that support the health care business or equivalent experience.
• Three years experience in a healthcare setting or as a provider of services to the healthcare industry.

Knowledge / Skills / Abilities

• Ability to perform the essential functions of the job as outlined above.
• Demonstrates knowledge of DNV, ISO 9001, CMS Conditions of Participation, and other regulatory agency requirements.
• Ability to effectively assist the hospitals and clinics in preparation for regulatory surveys by communicating all necessary information to the appropriate departments and recommending actions to maintain compliance.
• Outstanding team player and helps build teams.
• Ability to develop effective relationships with a broad array of people with various backgrounds.
• Superior organizational skills to manage a large volume of incoming data, information, reports, etc.
• Ability to create and deliver appealing and compelling presentations to various audiences, including clinicians, staff, faculty, administration, and governance groups.
• Excellent written and verbal communication skills.
• Demonstrates skill in change management and quality improvement.
• Knowledge of clinical/medical terminology.
• Strong computer skills including Microsoft Office platform—Teams, Word, Excel, PowerPoint, E-mail, Web/Internet.
• Ability to learn and effectively use computer software, such as electronic health records and data entry.
• Flexibility in work schedule.
• Able to have collaborative, objective investigative skills to perform audits.
• Able to work independently and function effectively in a team setting.

Qualifications

• Bachelor's degree required in a health care related fields such as nursing, laboratory, public health, healthcare administration or other fields that support the health care business or equivalent experience.
• Three years experience in a healthcare setting or as a provider of services to the healthcare industry.