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Senior Accreditation Specialist

2 months ago

Titusville FL United States Parrish Healthcare Full time
Job DescriptionDepartment:
Risk Management/QRM

Schedule/Status:
8am-430pm; Full Time

Standard Hours/Week:
40

General Description:
Under the general supervision of the Quality Manager, the Accreditation Coordinator is primarily responsible for coordinating and responding to initiatives related to the accreditation programs for The Joint Commission (TJC), Agency for Healthcare Administration (AHCA), the Centers for Medicare and Medicaid Services (CMS), and other regulatory agencies as appropriate. Promotes a continuous readiness program that emphasizes quality and patient safety at the forefront of regulatory compliance. Collaborates with accreditation and regulatory agencies, system leaders, content experts, executive sponsors, and medical staff leaders to develop an effective continuous readiness infrastructure that ensures the program and organizational goals are sustained through effective (1) Standard interpretation, (2) Standard compliance, (3) Education, training, and communication, and 4) Survey operations. Collaborates with colleagues on a state and national level to enhance the system's continuous readiness.

Key Responsibilities
Lead continuous readiness efforts
  1. Proactively coordinates the ongoing evaluation, planning and support of the continuous readiness infrastructure and processes to ensure accreditation by deemed status accrediting organizations such as The Joint Commission as well as other regulatory accreditation, certifications, and applicable organizational licenses.
  2. Support workflow needs and leverage the strengths of content experts and other accreditation and regulatory leaders to optimize processes. Collaborates regularly with accreditation and regulatory specialists to review work plans and progress. Identifies growth and areas of opportunity to ensure program initiatives are being met.
  3. Collaborates with Legal Services, Risk Management, Safety, and other departments to assure regulatory functions are addressed; Identifies regulatory vulnerabilities and determines appropriate corrective action; Partners with regulatory content experts to identify risk areas and support development, implementation, and monitoring of regulatory improvement processes.
  4. Coordinates organization-wide accreditation and regulatory compliance initiatives; Develops and manages the meetings and activities of the Accreditation and Regulatory Readiness Committee; Oversees project prioritization and timeline management of the Accreditation and Regulatory Program.
  5. Provides guidance on accrediting and certification standards interpretation and other regulatory requirements as they apply to organizational practice; Coordinates resolution initiatives for accreditation and regulatory compliance initiatives.

Resource development and management
  1. Develops tool kits, education and reference materials and provides presentations at leadership meetings; ensures regulatory resources are up to date, such as links to the CMS CoPs Interpretive Guidelines and other applicable regulations; and develops and implements initiatives to evaluate and monitor compliance with regulatory standards through ongoing organizational assessment, i.e. Intracycle Monitoring, Focused Standards Assessment, tracers, mock surveys, and measurement data.
  2. Coordinates the development and ongoing maintenance of an organizational communication and education plan for accreditation through internal communication channels

Collaborates with external partners.
  1. Serve as an organizational resource and leader in accreditation and regulation; serves as contact and point person for applicable standards-related manuals, publications and newsletters and educational materials; ensures pertinent information is communicated to appropriate individuals; serves as a resource to content experts and executive sponsors in standards and CoP interpretation, insight on upcoming regulatory changes, new requirements, along with exploring options for operationalizing requirements; and serves as an expert resource and leader in regards to deemed status accrediting organization, such as The Joint Commission accreditation and other regulatory activities and process.
  2. Develops, maintains, and implements organizational unannounced survey plans; coordinates onsite accreditation and regulatory surveys, including triaging presentation of surveyors, managing communications, agendas, and logistics for onsite survey activities; and serves as liaison between onsite surveyors and organization.
  3. Provides expertise in the development and implementation of action plans including measurement support as needed, for required follow up from the deemed status accrediting organization as well as other regulatory surveys and Intracycle Monitoring; finalizes and submits corrective action responses to regulatory agencies for survey; collaborates with content experts and executive sponsors to ensure corrective action plans are implemented, measures are in place and monitored to sustain accreditation.
  4. Ensures deemed status accrediting organization applications for accreditation are updated and submitted as required, as accurately as possible. Performs similar or related duties as assigned.
  5. Knows fire, disaster and safety procedures and regulations as it pertains to the work area.

Formal Education:
  • Bachelor's Degree in nursing required

Work experience:
  • Three (3) years' experience working in the healthcare industry, healthcare compliance and regulatory activity experience preferred. Project management experience a plus.

Required Licenses, Certifications, Registrations:
  • Current State of Florida RN Licensure required.
  • CPHQ, CJCP, or comparable credentialing strongly preferred.
  • Lean Six Sigma Green Belt preferred.

Full Time Benefits:
Eligible to participate in a number of PMC-sponsored benefits, including:
  • Annual Accrual of 152 Personal Leave Bank (PLB) Hours
  • Health, Dental and Vision Insurance
  • 403(b) Retirement Program
  • Tuition Reimbursement/Educational Assistance
  • EAP, Flex Spending, Accident, Critical and Other Applicable Benefits


Parrish Healthcare is a caring community of healthcare professionals passionate about excellence and fulfilling our mission of providing Healing Experiences For Everyone All The Time®.

Parrish Healthcare has a Culture of Choice®. This means a we have a healing work environment that empowers people to aspire to be their very best. We partner passionate, talented and skilled people in the right role with the right resources. We provide a clear and strategic direction to achieve superior results on behalf of the communities we serve.