Accreditation Officer

Scope of Position
The Accreditation Officer assists with ambulatory and inpatient operations amp; activities to comply with all accreditation, regulation, amp; licensing requirements. Translates various accrediting, regulatory amp; licensing agency requirements into action plans to achieve positive survey/audit reviews and with the guidance of the Director implements systems to effectively monitor compliance to standards amp; to implement new processes to meet new requirements. The Officer serves as a professional resource to interpret Joint Commission standards, Ohio Department of Health, Center for Medicare regulations and other accrediting agencies applicable to the hospital environment. Assists with review of policies to assure alignment with Joint Commission, Department of Health and CMS regulations. Assists other departments to design, coordinate, implement and evaluate their internal processes and policies to assure alignment with Joint Commission, Department of Health and CMS regulations.

Position Summary

The Accreditation Officer will serve as a subject matter expert on regulatory standards and policy development throughout the organization. This position will perform various audits and rounding techniques to monitor compliance, and compile data metrics to provide education on their findings. The Accreditation Officer will foster collaboration by using a multidisciplinary approach to support achievement of a culture of safety, improvement of service delivery and positive patient care outcomes. The Officer will participate in survey activities and demonstrates knowledge of governmental amp; other regulatory standards, requirements, amp; guidelines related to quality improvement, such as The Joint Commission, ODH, CMS Conditions of Participation, OSHA, FDA, HIPAA amp; Medical amp; Medicare regulations amp; standards. Has a strong working knowledge of ongoing monitoring techniques (including criteria development amp; statistical analysis); medical care delivery in hospital, total quality management principles, tools, amp; techniques. The Officer must have effective communication, negotiation and leadership skills.

For Hire: Bachelor's Degree in Nursing or a Healthcare related specialty. 2 years of relevant experience required. 2-4 years of relevant experience preferred. Maintains current Ohio RN license.

Ongoing: This person must demonstrate competency to meet essential job functions and the ability to adapt to the rapid changes that occur in the health care setting. Maintains and seeks new knowledge related to regulatory oversight, quality improvement, cost reduction, and current policies, procedures and protocols. The Officer must meet mandatory educational and health requirements.

FUNCTION: Health Care Administration

SUB-FUNCTION: Accreditation

CAREER BAND: Specialized

CAREER LEVEL: S2