Senior Compliance Coordinator, Accreditation Services

University of Iowa•Iowa City, IA

3d•Hybrid

About The Position

Under the general direction of the Associate Director, Accreditation Services, University of Iowa Health Care, the Senior Compliance Coordinator supports activities to assess, plan, monitor, and evaluate compliance with accreditation standards and regulations, including but not limited to Joint Commission, Centers for Medicare and Medicaid Services (CMS), Iowa Department of Inspections, Appeals, and Licensing (DIAL), and other accrediting agencies as appropriate. Manages, promotes, and conducts education and other programs about Joint Commission compliance assessment and staff education, including University of Iowa Community Clinics (UICC).

Requirements

Bachelor’s degree, preferably in a health care related field, or an equivalent combination of education and experience.
3 years of related experience.
Excellent written, verbal, and interpersonal communication skills.
Must be self-organized, work independently, and have demonstrated team-building skills.
Proficiency in Microsoft Office applications, including data management, is required.
The position will require frequent travel to regional ambulatory care clinics in the state. Applicant must have a valid Driver’s License, plus the ability to meet the University of Iowa Fleet Safety Program driving standards (University of Iowa Operations Manual Part V, Chapter 19).
Demonstrated experience working effectively in a welcoming and respectful workplace environment.

Nice To Haves

Knowledge of and/or experience with Joint Commission Standards and CMS Conditions of Participation.
Prior experience participating in Joint Commission surveys and state regulatory surveys.
Poise in teaching and consulting, flexibility, and creativity in problem-solving.

Responsibilities

Responsible for implementing, maintaining, and overseeing programs to ensure hospital compliance with all state and federal regulatory and accreditation standards at University of Iowa Health Care and off-site UI Health Care Ambulatory Care Clinics.
Maintain knowledge regarding accreditation standards, a database, and a reference library of current initiatives by accrediting agencies through timely review of regulatory guidelines, journals, and newsletters, and attendance at agency educational programs. Obtain and disseminate standards, regulations, etc., to those in the health system as necessary.
Coordinate implementation of training programs and other educational efforts for staff. Assist in developing, implementing, and providing oversight for the system to ensure staff are knowledgeable about regulatory standards.
Provide direction to department heads, managers, supervisors, healthcare providers, and staff to ensure health care services are provided in accordance with quality and safety standards established by state and federal regulations and national accrediting bodies.
Assist with implementing training programs and other educational efforts to ensure that all UI Health Care staff are knowledgeable about Joint Commission and CMS standards.
Oversee maintenance of knowledge base regarding accreditation standards, including the Joint Commission database and reference library of current safety standards and CMS regulations. Track current initiatives being taken by accrediting agencies through timely review of regulatory guidelines, journals, and newsletters.
Manage Accreditation Manager Plus (AMP) to improve compliance with the Joint Commission's accrediting and regulatory standards. Develop custom tracer content for special projects. Aggregate survey information for analysis and report to senior leadership.
Direct the UI Health Care onsite and Ambulatory Care Clinics Mock Survey Program. Plan and coordinate mock surveys and other audits to monitor and ensure continuous compliance with Joint Commission clinical care and safety standards. Aggregate survey information for analysis and report to senior leadership.
Assist with and oversee internal procedures for monitoring and detecting noncompliance, recommending corrective actions on such matters, and following-up to ensure that recommendations have been implemented. Coordinate standards review and monitoring activities, including annual or periodic reviews.
Assist with periodic reports to the UI Health Care Accreditation Steering Committee, the University Hospital Advisory Committee, and other governance and management entities regarding: Announced or potential changes in regulations and/or standards, Monitoring and evaluation of compliance with all current regulations and/or standards, Progress on implementation of new policies, procedures, and activities needed to ensure continuing compliance, Planned visits and surveys by external agencies and results of visits.