Accreditation Coordinator in Orofino, Idaho

This job was posted by https://idahoworks.gov : For more information,
please see: https://idahoworks.gov/jobs/2309563

Under limited direction, plans, organizes and maintains a process to
ensure organizational compliance with regulatory standards (DNV and CMS)
and continuous survey readiness. Serves as an internal consultant for
the interpretation of standards and functional measurement of
compliance. Develops performance improvement plans with management/staff
on an as needed basis. Interprets new regulations for education purposes
and implementation efforts.

General responsibilities include working collaboratively to maintain
compliance with accreditation requirements; using data to improve
quality of care, including data collection and analysis; coordinating
and facilitating meetings; assisting with ongoing collection of
information including deficiencies and opportunities for improvement.

Job Specific and Unique Knowledge, Skills and Abilities:

• Excellent verbal and written communication skills; customer service
  skills; ability to provide presentations to diverse audiences.
• Ability to work collaboratively across department and divisional
  lines.
• Well organized and detail oriented
• Ability to maintain strict confidentiality of protected health
  information.
• Ability to prioritize duties and projects; willing to work flexible
  hours to meet the needs of the department.
• Maintains general knowledge of the ISO 9001 requirements.

Essential Job Functions:

Serves as an accreditation resource for the organization, to include
Medical Staff and Leadership as requested.

Coordinates the logistics of the accreditation visits, survey
activities, and follow up (e.g. DNV annual surveys, state/CMS surveys,
complaint and validation surveys.

Facilitates reporting of accreditation issues to the appropriate leader
and follows up on investigation and actions taken to resolve the issue.

Facilitates investigation and written response for complaints received
from accreditation agencies.

Participates in analysis, development, implementation, and ongoing
maintenance of action plans and evaluation of strategic quality or
accreditation initiatives.

Communicates changes of standards/rules/requirements of the
accreditation agencies for accreditation/certification purposes to all
appropriate parties.

Contributes expertise to hospital/system and medical staff committees,
including meeting coordination and facilitation, as requested.

Provides educational opportunities and updates for SMH/CVH leadership
and staff on accreditation standards and requirements, as requested.

Completes updates to the accreditation application to meet vendor
requirements, including notification of new services.

Acts as a liaison between chapter owners and the Quality department in
the creation of data collection tools; assists owner with analysis of
data and identification of opportunities for improvement.

Facilitates reporting of data and barriers to compliance to the quality
oversight committee (QMC)

Serves as Internal Survey Program Lead and performs internal surveys,
based on high risk, high probability to maintain the organization’s
accreditation status and compliance with ISO 9001 requirements.

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