Accreditation Specialist

Albany Medical Center•Albany, NY

5d•$94,957 - $147,183

About The Position

The Accreditation Specialist performs chart review and abstraction, closed-record reviews, and audits to promote patient safety and ongoing compliance with accrediting organizations and CMS. The role supports the administration of the work unit or department and requires strong knowledge, competence, administrative support skills, and the ability to work with considerable independence. The specialist supports accreditation and regulatory compliance, survey preparation and follow-up, data collection and reporting, audit-system access and training, and improvement initiatives. The role also includes communication and record-keeping duties, presentations and meetings, Environment of Care rounds, and appropriate handling of sensitive health information.

Requirements

Demonstrated knowledge, competence, and administrative support skills.
Ability to operate with considerable independence.
Ability to use data analytics and databases to enter and organize data, run reports, and assist with interpretation.
Ability to use the audit system proficiently.
Ability to follow protocols for accessing, viewing, and distributing sensitive personal health information.
Ability to meet accreditation and CMS regulations and chart-review protocols.

Responsibilities

Independently gather and summarize information for reporting and other purposes.
Maintain knowledge of 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, stakeholders, and programmatic groups to resolve questions and issues and develop strategies to improve Leapfrog measures.
Perform chart audits on current inpatients and conduct tracers in patient care areas.
Coordinate and support logistics for survey preparation, survey activity, and deficiency corrective action.
Use data analytics and databases to enter and organize raw data, run reports, and help interpret results.
Follow protocols for accessing, viewing, and distributing personal health information needed for the job.
Copy, fax, and scan materials as needed; establish, maintain, and revise record-keeping systems.
Greet, identify, and direct internal and external staff and inquiries in person or by telephone; provide timely follow-up, information, and solutions or refer issues to the appropriate authority.
Lead Accreditation presentations and department-led meetings as necessary.
Proactively identify and examine organizational improvement opportunities.
Lead departmental Environment of Care Rounds in appropriate patient-care areas, including hospital and clinical settings.
Escalate barriers through the departmental chain of command when unable to mitigate them in a timely manner.
Assist with oversight of department intranet website content.
Perform additional duties as assigned.