Regulatory Accreditation Coordinator

Employment Type

Full time

Shift

Day Shift

Description

General Summary And Purpose :

Serves as a consultant and an educator to Medical Center providers, colleagues, management, and senior leaders related to standards interpretation, evaluation of compliance, development of performance measurement systems, and design and implementation of improvement programs. Designs, implements, coordinates, and evaluates the Joint Commission / CMS Conditions of Participation continuous readiness program. Provides facilitation for teams working on regulatory compliance processes.

Skills, Knowledge, Education And Experience :

Bachelor's Degree in Nursing or Bachelor's Degree required (healthcare related field preferred).

Two years of acute hospital or medical group experience.

Essential Functions :

• Develops and implements the activities of the organization-wide Joint Commission / CMS Conditions of Participation continuous readiness plan and continuously monitors the organization's state of readiness.
• Coordinates Joint Commission and CMS onsite surveys.
• Maintains records of all accreditation and certification programs.
• Facilitates interdepartmental, multidisciplinary teams to improve patient safety and regulatory compliance.
• Develops and implements a regulatory compliance education / communication plan. Provides formal education and individual consultation on standards interpretation, implementation and monitoring.
• Functions as a liaison to the health system regarding regulatory and patient safety functions.
• Develops, organizes and maintains databases related to patient safety and regulatory issues.
• Displays, analyzes, and communicates data regarding patient safety and regulatory issues.
• Exercises critical thinking skills in conjunction with ever changing, high priority issues.
• Communicates both verbally and in written format with providers, the public, other agencies, and hospital colleagues regarding patient safety and regulatory compliance issues.
• Regularly reports on the status of continuous readiness to managers, directors and senior leaders.

Colleagues of Saint Alphonsus Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout SAHS and Trinity Health.

Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness, dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race, color, religion, gender, marital status, national origin, age, disability, sexual orientation, or any other characteristic protected by law.

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.