Description

REPRESENTATIVE RESPONSIBILITIES

???Regulatory
Demonstrate the application of clear, accurate and current understanding of applicable state, local and federal requirements to allow accurate and timely identification of compliance and potential gaps. Identify and implement best practices for ongoing compliance of requirements through internal and external resources. Seek and review most up to date publications related to accreditation standards, survey preparation and other materials and demonstrate the application to CCHMC policies and operations. Facilitate policy change as required based on updated requirements/standards. Seek ongoing educational opportunities to stay current with standards and regulations.

???Survey
Leads and conducts survey preparatory on the applicable local, state, and federal standards such as the Joint Commission Comprehensive Accreditation Manual for Hospitals, Behavioral Health, and Home Care, as well as the applicable CMS Conditions of Participation, CARF (rehabilitation), etc. Conduct survey readiness assessments and mock surveys at all CCHMC patient care locations. Assume responsibility for assisting in the preparation of the staff for all accreditation surveys, as well as state surveys as required. Conduct routine audits and monitoring activities as part of ongoing readiness. Prepare and preform focused audits as needed . Serve as escort for surveyors and/or resource during any actual survey. Prepare staff as necessary for actual survey. Responsible for development, tracking, and ensuring completion of action items from survey findings.

???Compliance
Provide expertise on standards interpretation and application. Support clinical staff, leaders and executive staff, in developing and/or refining systems that support compliance with standards of accrediting bodies, as well as applicable law and regulation. Provide consultation, facilitation, or leadership on assigned committees and special projects as needed. Responsible for tracking and trending compliance issues.

Qualifications

EDUCATION/EXPERIENCE

Required:
???Bachelor's degree in a related field
??? 5 - 7 years of work experience in a related job discipline.