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Accreditation Specialist

3 weeks ago

Gainesville, GA, United States Northeast Georgia Health System Inc Full time
Job Category:
Nursing - Registered Nurse

Work Shift/Schedule:
8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:
Job Summary

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.
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.
  • Other:
Preferred Job Qualifications
  • Preferred Licensure or other certifications:
  • Preferred Educational Requirements:
  • Preferred Experience: Three (3) to five (5) years' experience in Quality. Healthcare accreditation experience.
  • Other:
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


Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.