The Accreditation Specialist II is responsible for tracking, trending and reporting Accreditation and Regulatory measures and compliance reports. Assists in the preparation and coordination of efforts related to The Joint Commission and multiple regulatory agency surveys and maintains a constant state of readiness for surveys and continuous process improvement needs in order to meet Regulatory Compliance. This includes maintaining knowledge of standards, updates to standards, compliance of regulatory requirements through comprehensive analysis, documentation, reporting of data.
This job description is intended to cover the minimum essential duties assigned on a regular basis. Caregivers may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
Serves on Hospital and Sparrow Health System committees related to accreditation.
Assists as directed with education on regulatory accreditation standards.
Assists with the creation and maintanance of infrastructure and environment to support continual readiness.
Provides education to promote regulatory compliance.
Assist with the completion of mock surveys and work with readiness team to address vulnerabilities or gaps
Creates and maintains spreadsheets to manange data for all post survey activities. Recommends solutions to identified problems.
Manages regulatory and accreditation surveys as directed by the System Director of Accreditation.
Creates and completes initial and annual accreditation training for Leaders.
Assists with the review, and revision of survey application.
Assists with preparation for the health system accreditation readiness team meetings
Assists with the health system mock survey process.
Assists with an annual assessment of accreditation readiness, including recommendations for improvements.
Completes the Focused Standards Assessment for Hospital. Develops action plans with standard owner and tracks data to insure success.
Participate in other survey-related activites as required
Supports more than 1 hospital so must be able to travel to various locations
* Must be willing to pursue certification in accreditation within 4 years of date of hire into this position
* Knowledge of CMS and other regulatory standards (Joint Commission) * Experience in formal/informal training and development of educational programs and project management skills - preferred
* RN Bachelors in healthcare related field and a minimum of one year accreditation or regulatory survey experience; OR Bachelors in healthcare related field and a minimum of three years of accreditation and regulatory survey experience. * Master's Degree in healthcare or related field - preferred
Specialized Knowledge and Skills
* Excellent verbal, written and interpersonal communication skills. * Exceptional analytical and statistical abilities. * Demonstrates superior organization and time-management skills. * High degree of professional judgment, flexibility, and professionalism. * Demonstration and understanding of organizational behavior, independent, creative problem solving, detail oriented and self-motivation to handle complex projects. * Ability to work independently with little supervision. * Ability to meet constant deadlines. * Exceptional attention to detail. * Must have strong knowledge base of Microsoft Excel, Word * Demonstrates ability to use a keyboard as may be required to perform the essential duties of the job. * Experience with database management (i.e. Access) - preferred
Travel up to 50%
Position will service Sparrow Specialty Hospital and Sparrow Medical Group Lansing area.
Sparrow Health System is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.