Accreditation Consultant

Employment Type: Full time Shift: Description: POSITION PURPOSE Provides leadership and expertise in the areas of external regulatory compliance, and quality and safety standards related to colleagues, medical staff, and inpatient and outpatient services. Supports the development, education, maintenance, consistent application, and accountability required to ensure regulatory compliance and accreditation readiness. The position will support Chelsea Hospital and Trinity Health Livingston (Howell). The selected candidate will rotate between the two locations. Full-Time benefited position scheduled 40 hours per week. WHAT YOU WILL DO Provides direction and expertise in the areas of external regulatory compliance, and quality and patient safety standards as it relates to colleagues, medical staff, and inpatient and outpatient services. Leverages clinical information technology, process design, change management and evidence to ensure ongoing survey readiness and compliance with accreditation regulations and standards. Supports specific initiatives related to external certification or recognition as reflected in the organization’s strategic quality and safety priorities. Assures the organization’s ongoing survey readiness and implementation of Zero Harm initiatives. Responsible for the consistent application, effective processes, and accountability for the regulatory clinical improvement programs and/or responsible for the compilation, analysis, evaluation, and continual monitoring of the regulatory quality data. Communicates and manages survey results, develops action plans and survey responses in accordance with regulatory timelines. Coordinates organizational response during CMS, state licensing surveys, and Joint Commission surveys. Manages the routine and ongoing functions of the accreditation software, Joint Commission extranet, and monitors the CMS.gov websites to assure compliance with regulatory reporting requirements. Minimum Qualifications Baccalaureate of Science in Nursing (BSN) degree from an accredited school of nursing. Valid RN licensure authorized in the applicable state(s) of practice/employment. Valid driver’s license where required by assignment. Minimum three (3) years’ experience in associated nursing specialty. Additional Qualifications (Preferred) Specialty credentialing & educational degree according to clinical nursing practice specialty area. Three (3) or more years of quality improvement background with preference given to the clinical area serving. Certification as a Joint Commission Professional (CJCP) preferred. Two to three years progressively more responsible related work experience in accreditation and regulatory activities preferred. Three (3) years of health care quality management and performance methodologies, tools, standards, and guidelines with past interaction with medical administration. POSITION BENEFITS AND HIGHLIGHTS Competitive compensation. Full benefits package including Medical, Dental, Vision, PTO, Life Insurance, Short and Long-term Disability. Benefits effective Day One No waiting periods. Retirement savings plan with employer match. Opportunity for growth and advancement throughout Trinity Health. Tuition Reimbursement. Our Commitment to Diversity and Inclusion Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is 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, status as a protected veteran, or any other status protected by law. #J-18808-Ljbffr