Accreditation & License Coordinator - ProHealth Care - 0.5 FTE

ProHealth Care•Waukesha, WI

5d•Onsite

About The Position

Responsible for the administration and oversight of activities to achieve continuous regulatory and survey readiness for ProHealth Care. This includes, but is not limited to, Centers for Medicare and Medicaid Services, Wisconsin Department of Health and Family Services and the Joint Commission. This activity will be in compliance with the philosophy, policies, procedures, goals and budget of the organization.

Requirements

Bachelor's Degree required.
Current State of WI or eLC compact state RN license.
At least 4 years of related experience.
Strong interpersonal and communication skills
Previous experience with coordination of accreditation activities.
Knowledge of accreditation standards, health care regulations.
Experience with process improvement, patient safety and policy formulation.
Previous experience implementing and facilitating organizational change.
Previous background in complex systems and cultural change.

Responsibilities

Serves as the system expert on regulations and standards from various accreditation bodies.
Facilitates strategic and operational implementation of regulatory requirements, guidelines and standards as applicable. This includes identifying and communicating revisions in standards or regulations and facilitating gap assessments.
Provides leadership and mentorship for collaborative team relationships in achieving continuous survey readiness.
Maintains measurable evidence of high levels of survey readiness. Monitors to ensure the medical staff, management, and staff are in a state of continuous compliance with the rules and regulations of all applicable regulatory agencies.
Coordinates and ensures action plans are completed to maintain survey readiness.
Prepares all required documentation for pre and post survey activities, including but not limited to applications and post-survey response.
Coordinates activities and is lead contact person during on site surveys.
Develops and deploys processes for ongoing tracer and mock survey completion.
Maintains a consistent set of tools related to accreditation across both campuses, striving for standardized process and tools whenever possible.
Applies performance improvement and change management principles to daily work.
Serves as a consultant to leaders within the organization, as leaders manage their departments according to standards.
Serves as the primary contact for ProHealth Care to various accrediting bodies.
Assures cross-campus collaboration and learning to spread best practice and nurture standardization.
Collaborates with the Center for Learning and Innovation to maintain current educational offerings with regards to survey readiness.
Collaborates with the Patient Safety Officer to ensure that the patient safety goals are met.
Collaborates with the Safety Officer to ensure that regulatory safety standards are met.
Liaison with various committees that may be impacted by regulatory standards.