Accreditation Coordinator

Position Summary / Career Interest:

The Accreditation Coordinator leads and/or assists the Manager in system-wide activities to evaluate and improve adherence to The Joint Commission (TJC) accreditation standards and CMS Conditions of Participation (CoPs), including ongoing readiness for accreditation surveys as well as regulatory complaint investigations. The mitigation of regulatory compliance risk will at all times focus on assuring the delivery ofsafe patient care.


Responsibilities and Essential Job Functions

• Assist in assuring accuracy and timeliness in submission to reporting centers ( i.e. Sterling Readiness Rounds)
• Collects, analyzes and reports data in support of continuous readiness activities
• Conducts patient and system tracers in patient care areas through observation of practice
• Disseminates the results of audits and surveillance as needed and as data is available
• Interpretation of relevance of standards in relation to hospital and clinic policies and practice
• Maintain databases and sources of information for quality initiatives, accreditation efforts, and regulatory mandates
• Performs concurrent and closed medical record review audits to assist in determining compliance with accreditation and regulatory requirements
• Provide practitioner data for Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) to Medical Staff Service as requested
• Serve as a resource for interpretation of regulatory, accreditation and disease-specific care certification standards (as applicable)
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• Bachelors Degree in Health Information Management from an accredited College or University OR
• Bachelors in Nursing, Respiratory Care or Clinical Laboratory Science
• High School Graduate

Preferred Education and Experience

• Master's Degree from an accredited College or University

Knowledge Requirements

• Excellent communication, writing, organizational and presentation skills; demonstrates superior oral and written communication and time management skills
• Advanced working knowledge of computer spreadsheets and databases.
• Must have strong knowledge base of Microsoft Excel, Word, and prefer experience with data management, ie Microsoft Access.
• Must be willing to drive to off-site hospital locations.

We are an equal employment opportunity employer without regard to a person’s race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, ancestry, age (40 or older), disability, veteran status or genetic information.