Accreditation Officer

Under the guidance of the Director of Accreditation, this position manages the hospital's day to day 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 manager serves as a professional resource throughout the health system to interpret Joint Commission standards, Ohio Department of Health, Center for Medicare regulations and other accrediting agencies applicable to the hospital environment. Responsible for the appropriate development and review of all hospital based 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 Manager of Accreditation is responsible for management of departmental operations, evaluation of employee performance, demonstrating customer satisfaction and strategic and operational planning and program development. The Accreditation Manager will serve as a subject matter expert on regulatory standards and policy development throughout the organization. The manager demonstrates knowledge of governmental amp; other regulatory standards, requirements, amp; guidelines related to quality improvement, such as The Joint Commission, NCQA, Federal HMO Act, 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 manager must have effective communication, negotiation and leadership skills.

Required Qualifications
For Hire: Bachelor degree in nursing or health care related field with 3 or more years of experience in a health care setting required.
Ongoing: This position must begin work toward a master degree in a related field within 24 months of employment. 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 manager must meet mandatory educational and health requirements.