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Job Description

MAIN FUNCTION:

The Clinical Accreditation Specialist acts as a consultant on interpretation of regulatory standards, including The Joint Commission and Centers for Medicare and Medicaid Services (CMS); ensures a constant state of readiness; advises on policy development, educates health care providers on the relevance of standards supporting a culture of safe, high-quality patient care, and contributes leadership and assistance to enterprise-wide initiatives.

Performance Improvement and Compliance:

Duties and Responsibilities:

** 1. Assumes the daily organizational responsibility for quality improvement and compliance for the Arnot Health System.

** 2. Directs all organizational continuous accreditation readiness activities.

** 3. Provides consultative services to all levels of the organization on accreditation/regulatory issues, interpretation of standards and policies, and linkage to clinical and operational processes.

** 4. Develops and implements a continuous readiness plan with scheduled activities designed to educate and engage all levels of staff and providers to sustain high performance per internal and external standards.

** 5. Coordinates formal on-site surveys for The Joint Commission and CMS, acting as primary liaison with the surveyor team, including overseeing and coordinating schedule, activities, and remediation of open issues.

** 6. Manages operational aspects of accreditation applications, ongoing standard’s assessments, development of corrective action plans for prioritized risks, and design of audits to evaluate effectiveness of improvements.

** 7. Organizes and delivers education and communication on continuous accreditation standards and readiness at all levels of the organization, including senior leaders, middle managers, physicians, and staff.

** 8. Partners with Safety & Risk Management and Infection Control on sustained compliance with the National Patient Safety Goals and other patient safety standards.

** 9. Partners with Quality Management and Performance Improvement to leverage opportunities to sustain compliance with best practices as part of existing improvement teams within operations.

** 10. Ensures documents required by accreditors/regulators are produced and updated and that those responsible for those documents are fulfilling their responsibilities.

** 11. Provides support and expertise to hospital administration’s policy and procedure committee with scheduled review and update to appropriate policies and access to all relevant parties.

** 12. Performs other related duties and participates in special projects as assigned.

Other:

** 1. Is responsible for attending all annual mandatory educational programs as required by position.

** 2. Understands and demonstrates the importance of satisfying the needs of the customer/patient by interacting with him/her in a friendly and caring way, being attentive to the customer’s needs, both psychologically and physically, and by taking the initiative to maintain communication with the customer to provide a secure and pleasant experience with the Arnot Health.

** 3. It is understood that this lists typical duties for the classification and is not to be considered inclusive of all duties, which may be assigned.

EDUCATION:

RN license required. Bachelor’s/master’s degree in healthcare-related field preferred . Certification is preferred – may include CPHA (Certified Specialist in Healthcare Accreditation), CPHQ (Certified Professional in Healthcare Quality), or other certifications relevant to this field.

EXPERIENCE:

** 1. Five (5) years of clinical and/or administrative experience in a healthcare setting, including specific experience related to accreditation and regulatory bodies, such as Joint Commission, CMS, and state licensing agencies required.

** 2. Must have a working knowledge of quality improvement methodologies, tools, and data management skills.

** 3. Leadership and change management skills required. Demonstrated analytical problem-solving skills.

** 4. Effective verbal and written communication skills, including presentation and training capabilities required.

** 5. General understanding of medical terminology and the Electronic Medical Record for the institution is required.

** 6. Ability to perform assignments independently with minimal supervision is required.

** 7. PC-based computer skills, including Microsoft Office required. Needs to be well versed with software for flow diagrams and mapping lean processes.

CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:

No CPR required.

PHYSICAL DEMANDS:

Routine office job

EXPOSURE CATEGORY:

Category III. Tasks that involve no exposure to blood, body fluids, or tissues. And Category I tasks are not a condition of employment.

** A.D.A Essential Functions

Requirements