Accreditation Coordinator

Reporting to the System Chief Quality Officer, The Accreditation and Regulatory Affairs Coordinator is responsible for continual system, hospital, and Phoebe Physician Group (PPG) hospital-based regulatory standards compliance and accreditation readiness. This individual serves as a central point of contact and liaison to internal stakeholders and external bodies. The Accreditation and Regulatory Affairs Coordinator is responsible for the development and implementation of a comprehensive system-wide program including implementation and leadership of the Accreditation Regulatory Committee, development of a measurement and tracking system for assessing level of compliance with the standards and action plans to address noncompliance, and development of the regulatory accreditation education plan for the organization. This role is responsible for accreditation application completion, coordination of survey and site visit activities, and coordination of response action plan to external agencies regarding deficiencies or nonconformities.

Education Requirements

4-year Bachelor's Degree in a relevant healthcare field (Required)

Experience Requirements

3 years in healthcare with an emphasis on accreditation and regulatory standards (Required)

Demonstrated knowledge of the CMS Conditions of Participation, State regulations, and DNV NIAHO standards (Required)

Knowledge Of Applicable State And Third-party Regulations (Preferred)

Demonstrated knowledge of quality improvement methodologies (Preferred)

CERTIFICATIONS AND LICENSURES

Essential Functions

DNV and/or ISO Certification (Preferred)

Coordination And Management

Facilitate and empower dept leaders to ensure that the organization meets all accreditation requirements and standards, identifying areas for improvement and addressing any non-compliance issues. Share and scale learnings and best practices across the system.

Identify and implement process improvements to streamline the accreditation and regulatory process and enhance outcomes and efficiency across the system.

Develop and retain qualified team members if/as applicable.

Establish, develop, and maintain effective collaborative working relationships with all levels of leadership across the system, direct and indirect reports, and physicians APPs to foster open communication and to ensure the achievement of organizational and departmental goals.

Assist operational leadership with all aspects of the accreditation and regulatory process, including but not limited to scheduling visits, developing teams, preparing materials, editing reports, maintaining records, and responding to inquiries.

Conduct regular audits, assessments, and mock surveys to identify areas of non-compliance. Partner with operational leadership toward resolution/optimization.

Documentation And Record Keeping

Maintain accurate and up-to-date documentation related to accreditation, including policies, procedures, reports, action plans, and other relevant materials.

Data Analysis And Reporting

Collect, analyze, and report on data related to accreditation and regulatory affairs, using this information to drive improvement and ensure ongoing compliance.

Facilitate operational leaders' access and use of data reports to identify opportunities and to drive accreditation and regulatory compliance.

Consultancy, Training And Education

Provide advice and support to the organization's leadership and staff on accreditation and regulatory matters.

Seeks opportunities to expand knowledge base through professional development. Create venues for sharing that learning with leaders and team members across the system.

Provide training and guidance to staff on accreditation standards and procedures, and any updates changes; facilitate assurance that everyone understands their roles and responsibilities.

Stays current on industry trends and best practices to ensure the organization remains at the forefront of accreditation and regulatory standards.