About the Job
Develops, maintains, and enhances mechanisms to track, trend, and report Accreditation and Regulatory Compliance measures and reports. Uses proactive data analytics to advise of potential regulatory risks. Assists and/or leads in the preparation and coordination of efforts related to major accreditations, major certifications, and multiple regulatory agency surveys. Supports the Accreditation and Regulatory Department in maintaining a constant state of readiness for all surveys and continuous process and quality improvement needs in order to meet regulatory compliance. Maintains knowledge of standards, updates to standards, compliance of regulatory requirements through comprehensive analysis, documentation, reporting of data, and summarizing.
Job Specific Duties
Analyzes data collected in organization related to survey activities and serves as a resource. Reviews, monitors, and analyzes data.
Serves as a resource for interpretation of state, regulatory, accreditation, and disease-specific care certification standards (as applicable) in relation to system wide policies and practices.
Promotes a standard and effective approach to ensure the organization is continually ready for all regulatory and/or accreditation surveys.
Assists the Accreditation & Regulatory team during all surveys, inspections, and audits.
Analyzes Environment of Care data/concerns and other quality/process improvement concerns related to state, federal, and national accreditation surveys. Evaluates corrective action plans as needed to ensure sustainability.
Performs routine audits and tracers to assist in determining compliance with accreditation and regulatory requirements.
Assists in tracking, trending, reporting issues, and monitoring Accreditation & Regulatory tracker data by accreditation standards.
Completes audits and projects as assigned by Accreditation & Regulatory Dept.
Actively participates in system wide or department specific preparation for accreditation and regulatory audits and surveys by creating and maintaining compliance roadmaps as assigned.
Supports the creation, analysis, maintenance, and reporting of all Corrective Action and Preventive Action (CAPA) and ISO Assurance Audit items for NCHS.
Minimum Job Requirements
Knowledge, Skills, and Abilities
- Bachelor's Degree Healthcare or related field
- 3-5 years Experience in healthcare/hospital, outpatient and urgent care centers, multi-location physician office practice, and/or ambulatory surgery center settings
- 1-3 years Experience in project management and analysis
- 2-4 years Experience with at least two Accreditation Surveys (DNV, TJC, AAAHC, etc.), as well as, other regulatory agencies where you served as a lead, scribe, and/or escort
- Master's Degree preferred.
- 3-5 years hospital experience preferred.
- Accreditation & Regulatory experience preferred.
- Previous experience in quality review, analysis, and reporting, as well as, quality background.
- Working knowledge of state, federal, and national accreditation standards in a hospital or healthcare related field.
- Excellent oral and written communication skills.
- Strong problem solving, organizational, and data management skills.
- Analytical and statistical abilities.
- Advanced knowledge of Microsoft Excel and Word; prefer experience with database management and Microsoft Access.
- Ability to meet constant, competing, and changing deadlines.
- Attention to detail and time management skills.