Accreditation and Licensure Coordinator - Quality & Safety

Wellstar Health System • Austell, GA

3d • Onsite

About The Position

The Quality & Safety team at Cobb Hospital has an exciting opportunity for a Accreditation and Licensure Coordinator! Under the leadership of the Director of Quality and Safety OR Accreditation and Licensure Manager, the Coordinator of Accreditation and Licensure serves as an expert to promote compliance of licensure, certification and accreditation standards among WellStar facility team members, leaders, and physicians. Responsibilities include but are not limited to: the development and facilitation of a cohesive survey readiness team. In addition, the role delivers education at all levels and assesses survey readiness through mock surveys and patient tracers including collaborating with hospital and system leaders to establish and monitor action plans for improvement.

Requirements

• Bachelors Nursing or Bachelors Other
• Minimum 2 years of experience in a healthcare setting.
• Strong attention to detail; meticulous accuracy and thoroughness
• Superior organizational and interpersonal skills with ability to work independently as well as with a team
• Demonstrated excellence in interpersonal and written communication skills required
• High degree of professionalism, discretion, and confidentiality
• Strong computer skills, including but not limited to Microsoft Office and accreditation software
• Proficiency in problem solving and negotiating teams to reach consensus
• Ability to build relationships and foster communication among stakeholders in clinical and non-clinical settings.

Nice To Haves

• Minimum 1 year with hospital accreditation and licensure programs (e.g. The Joint Commission, CMS) is preferred.

Responsibilities

• Maintains the Joint Commission extranet site including, but not limited to, the hospital application with each HOD or new hospital program addition, required document submission and official TJC communications.
• Collaborates with and supports hospital specific certification programs with all functions of survey preparation, implementation, and post survey requirements.
• Educates new or amended requirements based on audience level of need.
• Provides expertise in the development of action plans to resolve gaps.
• Develops audit and tracer tools to ensure clear and specific guidelines for inter-rater reliability.
• Analyzes data to produce information and knowledge.
• Utilizes accreditation software for auditing tracking compliance to standards.
• Coordinate local accreditation non-compliance standards to the system level Accreditation Committee.
• Review accreditation applications annually and as needed.
• Maintains and updates the required survey documents for unannounced surveys.
• Reviews, edits, and executes the hospitals Survey Implementation Plan.
• Serves as the hospitals representative for all surveys.
• Communicates survey progress and potential problems with the Quality and Patient Safety leader.
• Responsible for all post survey requirements including the timely submission of corrective action plans.
• Consults on policies at the hospital and system levels.
• Supports patient safety activities by conducting policy and procedure reviews to support Root Cause Analysis.
• Communicates new or revised policy and procedures to the members of the hospital teams.
• Performs other duties as assigned
• Complies with all Wellstar Health System policies, standards of work, and code of conduct.

Benefits

• Nationally ranked and locally recognized for our high-quality care and inclusive culture, Wellstar is one of Georgia’s largest and most integrated healthcare systems.
• Every day, 24,000+ of us work together to provide personalized care for patients at every age and stage of life – and our team members are the foundation of that care.
• Mission, Vision & Values At a time when the healthcare industry is changing rapidly, Wellstar remains committed to exceeding patients’ and team members’ expectations, while transforming healthcare delivery.
• OUR MISSION: To enhance the health and well-being of every person we serve.
• OUR VISION: Deliver world-class healthcare to every person, every time.
• OUR VALUES: We serve with compassion We pursue excellence We honor every voice
• Culture of Excellence Wellstar consistently receives attention and accolades from national organizations that set the standards for world-class care.
• Our system-wide practice of safety principles, assessing and addressing errors and seeking feedback from our patients and customers continually earns recognition for advances in safety and quality.
• Featured on the FORTUNE “100 Best Companies to Work For” list and Seramount 100 Best Companies list, we not only provide top-notch care for our patients, but also foster the culture of Wellstar as a Great Place to Work.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level