Accreditation/ISO Compliance Officer

Methodist Le Bonheur Healthcare•Schoolcraft, MI

20d

About The Position

If you are looking to make an impact on a meaningful scale, come join us as we embrace the Power of One! We strive to be an employer of choice and establish a reputation for being a talent rich organization where Associates can grow their career caring for others. For over a century, we’ve served the health care needs of the people of Memphis and the Mid-South. Leads and designs processes related to accreditation and ISO: 9001 compliance, including the Quality Management System and Internal Audit at both the System level and assigned facility. Serves as the subject matter expert in CMS Conditions of Participation, ISO: 9001, NIAHO, State agency, Internal Audits and other accreditation and certification requirements. Plans, directs, and implements risk-prioritized processes to support ongoing compliance and Quality Management System. Models appropriate behavior as exemplified in MLH Mission, Vision and Values. Working at MLH means carrying the mission forward of caring for our community and impacting the lives of patients in every way through compassion, a deliberate focus on service expectations and a consistent thriving for excellence. A Brief Overview Leads and designs processes related to accreditation and ISO: 9001 compliance, including the Quality Management System and Internal Audit at both the System level and assigned facility. Serves as the subject matter expert in CMS Conditions of Participation, ISO: 9001, NIAHO, State agency, Internal Audits and other accreditation and certification requirements. Plans, directs, and implements risk-prioritized processes to support ongoing compliance and Quality Management System. Models appropriate behavior as exemplified in MLH Mission, Vision and Values.

Requirements

High School Diploma or Equivalent
Bachelor's Degree Allied Health
Bachelor's Degree Nursing
Bachelor's Degree Healthcare Administration
Master's Degree Healthcare Administration
Master's Degree Nursing
Master's Degree Allied Health
3-5 years Minimum of three years progressively responsible experience in organizing, directing and participation in process improvement and/or regulatory compliance program in a hospital setting.
In lieu of degree, High school graduate or equivalent will be accepted with seven (7) year’s job relevant experience OR In lieu of degree, Registered Nurse or Allied Health Professional will be accepted with five (5) year’s job relevant experience.
Demonstrated knowledge and expertise in CMS Conditions of Participation, ISO: 9001, NIAHO/State Agency/Internal Audit and other accreditation certification requirements.
Strong communication skills including excellent verbal, written and presentation abilities with experience in conveying complex information to all Associates, from management to frontline.
Demonstrated capability in a collaborative approach to Quality Management Systems, including facilitation of corrective action planning, verifications of control, internal audit, and regulatory compliance.
Ability to consult, negotiate, and influence in situations deemed controversial and/or sensitive to achieve mutual decisions.
Ability to exercise discretion in what and how to communicate and educate.
Ability to interpret and apply complex statutes, regulations, standards, and certification requirements.
Applies risk-based thinking in all process design and management of internal audit and non-conformances.
Ability to work without close supervision and to exercise independent judgement.
Ability to organize multiple tasks and projects, manage time, and maintain control of own workflow.

Nice To Haves

Certified Professional in Healthcare Quality (CPHQ) National Association for Healthcare Quality PREFERRED

Responsibilities

Leads and directs the process for continuous accreditation and ISO: 9001 compliance at both the system level and for assigned facility(s).
Develops and coordinates the measurement of internal compliance through data collection, tracking/trending, analysis, and monitoring. Presents findings and recommendations for improvement.
Applies risk-based thinking to prioritize, design, and lead internal audits across the system; report results and facilitate corrective action plans.
Upon identification of non-conformities, works with appropriate stakeholders to facilitate development of correction action plans and verifications of control.
Educates all levels of Associates (leaders to frontline) on the principles and requirements of the Quality Management System, ISO: 9001, and accreditation standards and the processes required for compliance.
Provides presentations and updates to facility/system leadership and management review committees regarding accreditation/ISO: 9001 results & compliance, internal audits/corrective action plans status, and any component of the Quality Management System.
Leads the Hospital’s response to CMS investigations.
Designs/develops processes and coordinates external audits (DNV, ISO: 9001).
Provides expertise/advice during the development of clinical/operational/business policies and procedures to ensure CMS Conditions of Participation and accreditation, and ISO: 9001 standards are met or exceeded.

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