Accreditation Specialist

Northeast Georgia Medical Center•Gainesville, GA

1d•Onsite

About The Position

The Accreditation Specialist at Northeast Georgia Health System (NGHS) facilitates efforts to ensure NGMC Acute Care Services comply with standards, rules, and regulations set by accrediting/certification agencies such as DNV GL Healthcare, CMS, and Georgia Department of Community Health (DCH). This role involves overseeing compliance with NIAHO, CMS, and Georgia Rules and Regulations requirements, and serving as an expert resource and liaison for Physicians, Administration, Managers, and Staff on these matters. General responsibilities include collaborative work to maintain accreditation compliance, using data for quality improvement (including collection and analysis), coordinating meetings, and assisting with ongoing information collection regarding deficiencies and improvement opportunities. NGHS is dedicated to improving community health.

Requirements

Current licensure as an RN in the State of Georgia.
Bachelors Degree.
Graduate of state accredited School of Nursing.
A minimum of five (5) years professional nursing experience as an RN.

Nice To Haves

Three (3) to five (5) years’ experience in Quality.
Healthcare accreditation experience.
Excellent verbal and written communication skills.
Customer service skills.
Ability to provide presentations to diverse audiences.
Ability to work collaboratively across department and divisional lines.
Well organized and detail oriented.
Ability to maintain strict confidentiality of protected health information.
Computer skills to include excel, power point, word.
Ability to prioritize duties and projects.
Willing to work flexible hours to meet the needs of the department.
Maintains general knowledge of the ISO 9001 requirements.

Responsibilities

Serves as an accreditation resource for the organization, to include Medical Staff Leadership as requested.
Coordinates the logistics of the accreditation visits, survey activities, and follow up (e.g. DNV annual surveys, state/CMS surveys, complaint and validation surveys.
Facilitates reporting of accreditation issues to the appropriate leader and follows up on investigation and actions taken to resolve the issue.
Facilitates investigation and written response for complaints received from accreditation agencies.
Participates in analysis, development, implementation, and ongoing maintenance of action plans and evaluation of strategic quality or accreditation initiatives.
Communicates changes of standards/rules/requirements of the accreditation agencies for accreditation/certification purposes to all appropriate parties.
Contributes expertise to hospital/system and medical staff committees, including meeting coordination and facilitation, as requested.
Provides educational opportunities and updates for NGMC leadership and staff on accreditation standards and requirements, as requested.
Completes updates to the accreditation application to meet vendor requirements, including notification of new services.
Acts as a liaison between chapter owners and the Quality department in the creation of data collection tools; assists owner with analysis of data and identification of opportunities for improvement.
Facilitates reporting of data and barriers to compliance to the quality oversight committee.
Works collaboratively with the Internal Survey Program Lead to maintain the organization's accreditation status and compliance with ISO 9001 requirements.
Performs Internal Surveys, as assigned.
Completes special projects or assignments assigned by the department managers or director.