Accreditation Clinical Coordinator

3 weeks ago

Dallas, United States UT Southwestern Full time

Why UT Southwestern?

With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued patients and employees. With over 20,000 employees, we are committed to continuing our growth with the best professionals in the healthcare industry. We invite you to be a part of the UT Southwestern team where you’ll discover teamwork, professionalism, and consistent opportunities for growth.

Experience and Education

Bachelor’s or Master’s degree and/or five (5) years of experience in hospital or clinic setting.

Job Duties

Assists and/or facilitates regulatory readiness review activities to ensure all accreditation requirements are met at locations assigned. Leads tracer activities among staff to ensure continuous patient readiness and assist with preparation for survey site visits with hospital specific administration staff. Maintains systematic processes for self-assessment with particular emphasis on continuous survey readiness. Works collaboratively with all departments and leaders in developing, communicating, and implementing effective strategies for assessment, data collection and analysis, and distribution of findings and recommendations to the appropriate individuals, committees, and departments. Interpret accreditation standards, identify organizational gaps and facilitate implementation of processes to meet standards and/or close gaps. Develop appropriate action plan and monitoring tools to sustain compliance. Works in collaboration with all disciplines to ensure policies, procedures, and practices are compliant with regulatory standards. Current working knowledge of ethical, regulatory and accreditation requirements and ability to review and validate clinical practice and policy. Assist with reviewing and evaluating the policies and procedures for compliance to applicable standards and regulations. Demonstrates ability to interpret accreditation standards, identify organizational gaps and able to facilitate implementation of processes to meet standards and/or close gaps. Develop appropriate action plan and monitoring tools to sustain compliance. Assists regulatory readiness review activities to ensure all accreditation requirements are met at locations assigned.  Leads tracer activities among staff to ensure continuous patient readiness and assist with preparation for survey site visits with hospital specific administration staff.  Interpersonal skills to collaborate and participate with staff, administrators and various committees to ensure and provide regulatory support and compliance. Maintains systematic processes for self-assessment with particular emphasis on continuous survey readiness. Works collaboratively with all departments and Functional Chapter Leaders in developing, communicating, and implementing effective strategies for assessment, data collection and analysis, and distribution of findings and recommendations to the appropriate individuals, committees, and departments. Meets regularly with appropriate teams to provide support, assess compliance, review findings, and provide guidance for improvement as needed in order to maintain continual survey readiness.  Works in collaboration with all departments to ensure that all required regulatory submissions and follow-up, including the annual FSA/PPR, Evidence of Standards Compliance (ESC), response to TJC or CMS complaint investigations and action plans are appropriate and completed in a timely and thorough manner. Communicates unresolved variances or areas of continued non- compliance with Manager and/or Director of Accreditation and Policy Management as well as leadership as appropriate for follow-up and action plan. Coordinate the communication with respect to anticipation of future trends and changing CMS and TJC standards to advise the organization in order to allow adequate time for appropriate response. Assists and be a resource to assigned committees, management, and staff. Provides ongoing education and interpretation of standards and the survey process to all levels of staff. Assist/Facilitates regulatory readiness review activities to ensure all certifications and designation requirements are met as it applies to individual external regulatory bodies, professional associations.  Be a liaison between the program and hospital leadership; channel of communication. Assist in planning the survey readiness rounds and in communicating the results.  Coordinate the clinical follow up to accreditation/certification surveys and applications. Collaborates with other departments to address compliance issues and execute resolution.

This position is security-sensitive and subject to Texas Education Code §51.215, which authorizes UT Southwestern to obtain criminal history record information. UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status. 

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