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At Children’s, the region’s only full-service pediatric healthcare center, our people make us the very best for kids. Come cultivate your passion, purpose and professional development in an environment of excellence and inclusion, where team members are supported and deeply valued. Opportunities for career growth abound as we grow our services and spaces, including the cutting-edge Hubbard Center for Children. Join our highly engaged, caring team—and join us in providing brighter, healthier tomorrows for the children we serve. Children's is committed to diversity and inclusion. We are an equal opportunity employer including veterans and people with disabilities.

A Brief Overview

The Accreditation and Regulatory Program Coordinator manages Children's survey readiness leading to surveys and coordination of activities during regulatory agency visits for the purpose of enhancing the triennial review process for all organization-wide and department-level surveys, inspections, and agency investigations. The Accreditation Program Coordinator interprets internal/external business challenges and recommends best practices to improve products, processes, or services. This role may lead functional teams or projects with moderate resource requirements, risk, and/or complexity. Leads others to solve complex problems and helps to identify innovative solutions. The Accreditation Program Coordinator works independently, with guidance in only the most complex situations, and impacts the achievement of customer, operational, project, and/or service objectives. This role communicates difficult concepts and negotiates with others to adopt a different point of view.

Essential Functions

Lead continuous readiness efforts and serve as an organizational resource and leader in accreditation and regulation

+ Maintains up-to-date knowledge of TJC/CMS regulations for all applicable programs (Hospital, Home Care, Transplant, End Stage Renal Disease, etc.)

+ Ensures timely and appropriate communication of all new and updated regulatory requirements to provide guidance to the organization and clinical and non-clinical departments

+ Facilitates the development and implementation of newly adopted clinical and non-clinical policies and procedures through active collaboration with the originating departments; facilitates the revision of current policies by providing direction in meeting and maintaining compliance with regulatory requirements

+ Assists the organization with regulatory compliance and provides direction to designated department leaders, monitors compliance with regulatory requirements at all levels of implementation

+ Maintenance and support of the centralized survey tracer and audit database which provides tools to assist with a consistent assessment of organizational and departmental compliance with regulatory requirements

+ Leads in the internal mock survey program, which includes planning, development of tools, training, conducting mock surveys, reporting findings, and follow-up as needed

+ Works with leadership to plan, facilitate, participate, and follow up on findings of consultative surveys which include scheduling, contracting, and billing

+ Performs walking rounds regularly to mentor leaders and staff and reinforce expected practices related to TJC, CMS, state law and regulation, and organizational policy/procedure

+ Works with the Marketing Department to maintain and refresh the TJC resources available to staff on the internal intranet site.

+ Maintains a collaborative relationship with the Organization's Hospital Association’s Accreditation/Regulatory Forum

+ Serve as liaison with contracted consulting agency

Manage all ongoing application requirements, plan, and coordinate accreditation and/or regulatory surveys, and oversee corrective action plans

+ Leads annual intracycle monitoring, report findings and develop action plans, while monitoring metrics as required

+ Oversee TJC website and communicate to appropriate audiences. Maintains necessary documents

+ Leads survey preparations and serves as a leader during an actual survey by escorting and organizing other survey escorts/scribes

+ Oversees and provides training to command center staff during a survey

Education Qualifications

+ Bachelor's Degree In Nursing, Business, Healthcare Administration, Healthcare Information Management, or a related field from an accredited college or university Required and

+ Master's Degree Preferred

Experience Qualifications

+ Minimum 3 years of experience in the healthcare-related industry Required and

+ Minimum 3 years of experience with health care compliance and regulatory activities Preferred and

+ Two years of project management experience and/or leadership experience Preferred

Skills and Abilities

+ Leadership skills

+ Knowledge of deemed status accrediting organization standards and regulatory compliance issues

+ Experience applying quality management/performance improvement and customer service approaches

+ Demonstrated capabilities with Microsoft-based software applications including Word, Excel, Teams, PowerPoint, Outlook

+ Understanding standards & regulations related to clinical documentation with the ability to read and assess documentation for compliance, quality and safety; also ability to read medical records to assess response with regulatory compliance reviews such as TJC, CMS, and accrediting/regulatory programs.

+ Excellent verbal and written communication skills

+ Project manage large organizational-wide initiatives

+ Problem solve & make decisions

+ Interpret legal and regulatory documents

+ Critical thinking for assess appropriate documentation sharing and communication with surveyors

Licenses and Certifications

+ RN - Registered Nurse - State Licensure and/or Compact State Licensure If filled by a nurse - current and valid Nebraska RN license/RN compact license. Required and

+ Health Services\BCLS - Basic Life Support If filled by a nurse - current and valid Basic Life Support (BLS) required if filled by a nurse. Through the American Heart Association Required and

+ HACP - Healthcare Accreditation Certification Program or equivalent within 3 years of hire. Required

Children’s is the very best for kids and the very best for your career! At Children’s, we put YOU first so together, we can improve the life of every child!

**Requisition ID** : 22752