Accreditation Specialist

Albany Medical Center•Albany, NY

About The Position

The Accreditation Specialist works in Quality Management and is responsible for chart abstraction and closed-record review, along with audit activities that promote patient safety and ongoing compliance with accrediting organizations and CMS. The role supports the department or division head in administering the work unit and requires strong subject-matter knowledge, competence, administrative support skills, and the ability to work with considerable independence. The specialist gathers and summarizes information, maintains knowledge of applicable standards and regulations, and uses audit systems and data tools to support reporting and interpretation. The role also supports survey preparation and follow-up, coordinates with leaders and stakeholders to address issues, helps users access and learn the audit system, and identifies opportunities to improve organizational performance. Work includes handling sensitive health information in accordance with applicable policies and privacy requirements.

Requirements

Demonstrated high degree of knowledge and competence.
Administrative support skills and ability to operate with considerable independence.
Ability to use data analytics and databases to enter and organize data, run reports, and assist with data interpretation.
Ability to use an audit system proficiently.
Ability to follow protocols for access to, viewing, and distribution of personal health information.
Ability to meet accreditation and CMS regulations for chart-review protocols.

Responsibilities

Independently gather and summarize information for reporting and other purposes.
Pursue continued education on standards, regulations, and requirements established by DNV, CMS, New York State, DOH, OSHA, and other regulatory bodies.
Use the audit system proficiently and assist users with access and training.
Work with departmental leadership and other stakeholders to resolve questions and issues.
Use data analytics and databases to enter and organize raw data, run reports, and help interpret results.
Access, view, and distribute personal health information using proper protocols.
Perform chart audits on current inpatients and conduct tracers in patient care areas.
Coordinate and support logistics during survey preparation, survey activity, and deficiency corrective action.
Copy, fax, and scan materials as needed to communicate for the department.
Establish, maintain, and revise record-keeping systems.
Meet accreditation and CMS chart-review requirements and assist the department in doing the same.
Greet, identify, and direct internal and external staff and inquiries in person or by telephone, and follow up as needed.
Provide information, identify solutions to issues, and refer matters to the appropriate person or authority when needed.
Respond in a timely manner to personnel questions and requests.
Work with programmatic groups to develop and implement strategies to improve Leapfrog measures.
Lead Accreditation presentations and other Accreditation Department meetings as needed.
Proactively identify and examine opportunities for organizational improvement.
Lead departmental Environment of Care Rounds in appropriate patient care areas, including hospital and clinical settings.
Escalate barriers through the departmental chain of command in a timely manner when unable to mitigate them.
Assist with oversight of the department intranet website content.
Perform additional duties as assigned.