Accreditation Specialist

Texas Children's Medical Center•Houston, TX

About The Position

We’re looking for an Accreditation Specialist to work as part of the Quality & Outcomes Management Team to achieve cost effective health care throughout Texas Children's IDS and maintain necessary accreditation status for the organization. Think you’ve got what it takes? Key Responsibilities Supports the Continuous Service Readiness program Participates in the internal mock survey program, which includes planning, development of tools, training, conducting mock surveys, reporting findings and follow-up as needed Works with leadership to plan, facilitate, participate, and follow-up on findings of consultative surveys. Participates in actual unannounced JC/CMS/TxHHS surveys. Role includes preplanning, education, active participation in survey, and required follow-up. Participates in conducting annual ICM. Report findings and develop action plans. Monitor metrics on a monthly basis as required. Coordinates regulatory educational offerings including internal and external presentations Oversee JC Accreditation website and communicate to appropriate audiences. Maintains documents necessary for the system. Oversees and coordinates with IS the installation of Accreditation Manager Plus (AMP) site licenses. Provides education and training to the AMP end users. Represents Accreditation in formal and informal settings at TCH and in the healthcare community. Represents Accreditation at TCH committee meetings and programs, as assigned. Prepares agendas, reports, and minutes as assigned, on time and error-free Provide regulatory consulting and analysis services to TCH IDS staff and physicians. Serves as TCH liaison to JCR for coordination, scheduling, contracting, and billing of mock survey visits. Serves as JCR Advisory Panel representative. Communicates with Joint Commission SIG group for questions regarding interpretation of accreditation issues. Inform appropriate parties of SIG ruling. Actively commits to the on-going development of self and maintain current knowledge of accreditation and regulatory standards. Develops regulatory articles and newsletters for the organization error free and on time Develops presentations with style, accuracy and professionalism as evidenced by error free presentation. Includes not only power point but written material as well. Maintains up to date knowledge of JC/CMS/TxHHS regulations for all applicable programs, as evidenced by direct observation by leadership. Conducts consultative mock surveys independently throughout the IDS. Evidenced by direct observation of leadership and customer feedback. Participation in other departmental operations. Provide input related to the development of the operating budget. Acts as a Facilitator or Team Leader on projects as assigned. Conducts special projects as assigned at the direction of leadership Knowledge & Skills Strong knowledge of JC standards, CMS requirements, TxHHS regulations, medical staff rules, utilization and case management principles, and organizational practices. Excellent verbal and written communication skills, with the ability to convey complex regulatory and quality concepts. Ability to identify and solve problems independently, collaborate effectively across departments, and thrive in a team environment. Strong analytical, organizational, and project management skills.

Requirements

Bachelor’s Degree
CPHQ; RN or other clinical discipline
Minimum 2 years of clinical, quality, and/or accreditation experience
Strong communication, analytical skills, regulatory knowledge, and ability to collaborate across departments.

Responsibilities

Supports the Continuous Service Readiness program
Participates in the internal mock survey program, which includes planning, development of tools, training, conducting mock surveys, reporting findings and follow-up as needed
Works with leadership to plan, facilitate, participate, and follow-up on findings of consultative surveys.
Participates in actual unannounced JC/CMS/TxHHS surveys. Role includes preplanning, education, active participation in survey, and required follow-up.
Participates in conducting annual ICM. Report findings and develop action plans.
Monitor metrics on a monthly basis as required.
Coordinates regulatory educational offerings including internal and external presentations
Oversee JC Accreditation website and communicate to appropriate audiences.
Maintains documents necessary for the system.
Oversees and coordinates with IS the installation of Accreditation Manager Plus (AMP) site licenses. Provides education and training to the AMP end users.
Represents Accreditation in formal and informal settings at TCH and in the healthcare community.
Represents Accreditation at TCH committee meetings and programs, as assigned.
Prepares agendas, reports, and minutes as assigned, on time and error-free
Provide regulatory consulting and analysis services to TCH IDS staff and physicians.
Serves as TCH liaison to JCR for coordination, scheduling, contracting, and billing of mock survey visits.
Serves as JCR Advisory Panel representative.
Communicates with Joint Commission SIG group for questions regarding interpretation of accreditation issues. Inform appropriate parties of SIG ruling.
Actively commits to the on-going development of self and maintain current knowledge of accreditation and regulatory standards.
Develops regulatory articles and newsletters for the organization error free and on time
Develops presentations with style, accuracy and professionalism as evidenced by error free presentation. Includes not only power point but written material as well.
Maintains up to date knowledge of JC/CMS/TxHHS regulations for all applicable programs, as evidenced by direct observation by leadership.
Conducts consultative mock surveys independently throughout the IDS. Evidenced by direct observation of leadership and customer feedback.
Participation in other departmental operations.
Provide input related to the development of the operating budget.
Acts as a Facilitator or Team Leader on projects as assigned.
Conducts special projects as assigned at the direction of leadership