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Description

Summary:

Leads efforts to ensure continual organizational compliance and ongoing readiness with clinical quality and patient safety standards and regulations required by The Joint Commission, North Carolina Department of Health and Human Services (NCDHHS) and Center for Medicare and Medicaid Services. In this role the Accreditation Manager proactively plans, implements, coordinates and continually improves Wayne UNC Health’s efforts related to compliance, accreditation, and licensure requirements.

Responsibilities:

1. Serves as the organizational expert for The Joint Commission, NCDHHS and CMS standards, regulations and conditions of participation.

• Communicates relevant changes to appropriate leaders and staff.

2. Provides education and consultation to administrative and clinical leadership, staff and faculty throughout Wayne UNC regarding the requirements of accreditation and regulatory organizations, using both formal and informal venues, e.g. presentations, publications, email, computer-based methods.

3. Leads continuous readiness efforts and coaches others in the development of accreditation improvement capabilities.

• Provides direction to department and facility leadership in planning of a systematic, organization-wide approach to continuous regulatory readiness.

• Coordinates the planning and execution of The Joint Commission (TJC) Annual Period Performance Review (PPR).

• Coordinates regulatory compliance and accreditation activities as assigned.

4. Maintains expert competence in accreditation (e.g. TJC, CARF, OIG, CAP as applicable) and regulatory standards.

5. Facilitates assessments, develops, implements and evaluates corrective action plans.

• Utilizes records of past reviews, surveys and tracer activities to develop action plans.

• Compiles and distributes compliance reports including appropriate action plans to oversight councils.

• Supports and guides the facility in continuous survey readiness efforts.

6. Maintains The Joint Commission accreditation and all applicable licensure/regulatory requirements for the department as evidenced by:

• Demonstrating knowledge of, adhering to, and promoting hospital and department safety regulations, disaster plans, emergency codes, infection control policies, fire safety regulations, and hazardous material disposal.

• Ensuring full compliance with Employee Health and Infection Control program including annual surveillance program.

• Accepting responsibility for the care and maintenance of System equipment.

• Maintaining current knowledge of legal issues that may impact department.

• Supporting efforts to ensure corporate compliance.

7. Works closely and builds effective working relationships with accreditation and regulatory agencies, i.e., The Joint Commission, DPH and CMS.

8. Leads a coordinated response to unannounced external accrediting or regulatory agency visits such as DPH, Joint Commission or CMS.

9. Coordinates responses to complaints from TJC, CMS NCDHHS or other regulatory bodies.

10. Other duties as assigned is not essential and covered in Compliance Expectations for All Teammates, below.

Other information:

Education

Bachelor’s degree in Nursing preferred.

Licensure/ Certification

Registered Nurse in North Carolina preferred

Experience

• Minimum 5 years’ experience in accreditation/licensing/regulatory compliance/ quality/performance improvement/patient safety in healthcare; Prior experience leading or managing teams preferred.

Knowledge, Skills and Abilities

• Working knowledge of hospital practices and protocols as well as applicable regulations and guidelines. Proven ability to analyze, interpret and display data.

• Strong attention to detail, meticulous accuracy and thoroughness.

• Ability to demonstrate leadership qualities, e.g., maturity, job knowledge, professionalism, communication skills, etc. to lead, guide and motivate others.

• High degree of professionalism, discretion and confidentiality.

• Ability to build collaborative relationships and foster communications among stakeholders in clinical and non-clinical settings. • Excellent organizational interpersonal and customer service skills.

• Highly proficient with MS Office and able to learn new software rapidly.

Valid NC Driver’s License: No

If driving a Wayne UNC Vehicle, must be 21 years old and MVR must be approved by Risk Management.

Job Details

Legal Employer: Wayne Health

Entity: Wayne UNC Health Care

Organization Unit: Corporate Compliance

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: WAYNE MED

Exempt From Overtime: Exempt: Yes

Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.