Accreditation and Compliance Specialist II

2 days ago


Portland, Maine, United States MaineHealth Full time

Job Summary

The Accreditation and Compliance Specialist II will play a crucial role in ensuring our organization's adherence to accreditation and licensing standards. This 32-hour position requires working 5 days a week and involves assisting leaders and managers in assessing our compliance with these standards.

Key Responsibilities

  • Assist in assessing adherence to accreditation and licensing standards
  • Support efforts to improve and maintain adherence to standards by providing reports to highlight gaps and helping develop action plans as appropriate
  • Organize mock surveys and readiness audits
  • Maintain an up-to-date Quality Assurance and Performance Improvement (QAPI) plan
  • Coordinate activities during surveys
  • Maintain relevant information on file and readily accessible during surveys
  • Communicate results after accreditation surveys
  • Help draft and submit a plan of correction
  • Lead inter-professional teams in addressing survey deficiencies

Requirements

  • Education: Associate's degree with at least five years of relevant healthcare experience OR bachelor's degree with at least three years of relevant healthcare experience required
  • License/Certifications: N/A
  • Experience: See "Education." Experience working with inter-professional teams in addressing organization-wide problems
  • Familiarity with The Joint Commission, CMS and State accreditation standards required
  • Familiarity with performance improvement tools and concepts, e.g., plan-do-study-act, preferred
  • Proficiency in Microsoft Office suite or equivalent preferred
  • Familiarity with electronic health records preferred
  • Effective verbal and written communication skills
  • Strong critical thinking skills and attention to detail
  • Collaborative and team oriented

About MaineHealth

MaineHealth is a health system whose members and affiliates include hospitals, physician practices, long-term care facilities, home care agencies, and support services. Learn more about this system at www.mainehealth.org



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