RN Accreditation Specialist

Overview

The Accreditation Specialist facilitates endeavors which aim to position NGMC Acute Care Services for successful compliance with standards/rules/regulations of the accrediting/certification agencies with which the Quality & Accreditation Department has been directed to collaborate (e.g. DNV GL Healthcare, CMS, Georgia Department of Community Health- DCH). Oversees compliance with NIAHO, CMS and Georgia Rules and Regulations requirements. Serves as an expert resource/liaison for Physicians, Administration, Managers and Staff regarding NIAHO, CMS and Georgia Rules and Regulations. General responsibilities include working collaboratively to maintain compliance with accreditation requirements; using data to improve quality of care, including data collection and analysis; coordinating and facilitating meetings; assisting with ongoing collection of information including deficiencies and opportunities for improvement.

Job Specific and Unique Knowledge, Skills and Abilities

• Excellent verbal and written communication skills; customer service skills; ability to provide presentations to diverse audiences

• Ability to work collaboratively across department and divisional lines.

• Well organized and detail oriented

• Ability to maintain strict confidentiality of protected health information

• Computer skills to include excel, power point, word

• Ability to prioritize duties and projects; willing to work flexible hours to meet the needs of the department

• Maintains general knowledge of the ISO 9001 requirements

Essential Tasks and Responsibilities

• Serves as an accreditation resource for the organization, to include Medical Staff Leadership as requested.

• Coordinates the logistics of the accreditation visits, survey activities, and follow up (e.g. DNV annual surveys, state/CMS surveys, complaint and validation surveys).

• Facilitates reporting of accreditation issues to the appropriate leader and follows up on investigation and actions taken to resolve the issue.

• Facilitates investigation and written response for complaints received from accreditation agencies.

• Participates in analysis, development, implementation, and ongoing maintenance of action plans and evaluation of strategic quality or accreditation initiatives.

• Communicates changes of standards/rules/requirements of the accreditation agencies for accreditation/certification purposes to all appropriate parties.

• Contributes expertise to hospital/system and medical staff committees, including meeting coordination and facilitation, as requested.

• Provides educational opportunities and updates for NGMC leadership and staff on accreditation standards and requirements, as requested.

• Completes updates to the accreditation application to meet vendor requirements, including notification of new services.

• Acts as a liaison between chapter owners and the Quality department in the creation of data collection tools; assists owner with analysis of data and identification of opportunities for improvement.

• Facilitates reporting of data and barriers to compliance to the quality oversight committee.

• Works collaboratively with the Internal Survey Program Lead to maintain the organization's accreditation status and compliance with ISO 9001 requirements.

• Performs Internal Surveys, as assigned.

• Completes special projects or assignments assigned by the department managers or director.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Frequently 31-65% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Frequently 31-65%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Occasionally 0-30%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving

Minimum Job Qualifications

• Licensure or other certifications: Current licensure as an RN in the State of Georgia.

• Educational Requirements: Bachelors Degree. Graduate of state accredited School of Nursing.

• Minimum Experience: A minimum of five (5) years professional nursing experience as an RN.

Preferred Job Qualifications

• Preferred Experience: Three (3) to five (5) years experience in Quality. Healthcare accreditation experience.

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