Accreditation Coordinator RN

Baptist Health•Jacksonville, FL

1d•Onsite

About The Position

Responsible for all aspects of planning and implementation of compliance activities for accreditation and/or regulatory agencies requirements, including Joint Commission and CMS. Responsible for development and implementation of educational activities related to accreditation. This includes disseminating interpretations of standards to all appropriate staff with respect to all the organization's functions. Oversees and manages survey readiness methodologies. Assesses, monitors, and recommends, as appropriate, activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards. Works with staff from all relevant areas to communicate, plan for, monitor, and evaluate new developments in regulation, standards, or legislation. Identifies plans, educates, and assists in implementation of change as required by new/evolving standards. Develops methodologies to support departments in achieving and exceeding continual compliance requirements. Responsible for documentation and other information as requested by regulatory and accrediting bodies, including, but not limited to, submission of applications, Focused Standards Assessment (FSA), and action plans in a timely manner. Coordinates site visits, follow-up reports, compliance activities, and historical files. Trains all new management staff on their role in accreditation and survey activities. Periodically reports to the leadership team announced and/or potential changes in regulatory standards; related implementation plans to assure compliance; monitoring and evaluation of compliance; progress on implementation of policies and procedures and activities necessary to assure continuous compliance; planned visits by external agencies and results of visits.

Requirements

Bachelor's degree in related health field required
Minimum 5 years clinical acute care hospital experience required
Minimum 3 years experience in TJC accredited facility required
Active RN license required
Proficient in use of Microsoft Word and Excel programs
Advanced computer skills to maintain databases, spreadsheets and develop reporting tools/graphs/control charts
Knowledge of accrediting and regulatory agencies procedures and standard requirements
Excellent interpersonal skills to interact with physicians and other professionals
Exceptional interpersonal communications, teaching/presentation and writing skills, analytical and strong team building skills
Knowledge of process improvement methodologies
Self-directed and highly motivated with problem solving abilities
Independent decision-making skills
Ability to adapt to change and adjust job responsibilities as the organization and outside regulatory agencies mandate
Ability to travel between organization's locations and to outside educational programs when required

Nice To Haves

Masters degree preferred
Prefer Medical/Surgical Unit and quality, patient safety and regulatory compliance-related experience
Regulatory survey coordination experience strongly preferred
Experience in project management, group facilitation and leadership group presentations preferred

Responsibilities

Planning and implementation of compliance activities for accreditation and/or regulatory agencies requirements, including Joint Commission and CMS.
Development and implementation of educational activities related to accreditation.
Disseminating interpretations of standards to all appropriate staff with respect to all the organization's functions.
Overseeing and managing survey readiness methodologies.
Assessing, monitoring, and recommending activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards.
Working with staff from all relevant areas to communicate, plan for, monitor, and evaluate new developments in regulation, standards, or legislation.
Identifying, planning, educating, and assisting in the implementation of change as required by new/evolving standards.
Developing methodologies to support departments in achieving and exceeding continual compliance requirements.
Responsible for documentation and other information as requested by regulatory and accrediting bodies, including submission of applications, Focused Standards Assessment (FSA), and action plans in a timely manner.
Coordinating site visits, follow-up reports, compliance activities, and historical files.
Training all new management staff on their role in accreditation and survey activities.
Periodically reporting to the leadership team announced and/or potential changes in regulatory standards; related implementation plans to assure compliance; monitoring and evaluation of compliance; progress on implementation of policies and procedures and activities necessary to assure continuous compliance; planned visits by external agencies and results of visits.