Metro Health is seeking a Compliance and Accreditation Coordinator.
General Summary:
The Compliance and Accreditation Coordinator assists the Compliance Officer with the oversight, direction and effective implementation of the Corporate Compliance Program and all accreditation initiatives. Under the direction of the Compliance Officer, assists with compliance and accreditation activities including but not limited to: the assessment and identification of compliance risk; the development and implementation of educational programs addressing accreditation and compliance, and Code of Conduct, for staff and physicians; communicating the importance of reporting compliance concerns; and identifying and conducting evaluations relative to compliance standards. The Compliance and Accreditation Coordinator is required to maintain knowledge of compliance concepts and accreditation standards to promote continuous readiness and compliance with all regulations and the Centers for Medicare and Medicaid Services (CMS) Conditions of Participation.
Requirements:
- Bachelor’s Degree in Nursing (BSN). Master’s degree preferred.
- Three (3) to five (5) years of health care compliance and / or accreditation experience preferred.
- Knowledge of accreditation standards and regulations with the ability to interpret standards and translate them into organizational policy.
- Ability to analyze compliance problems and develop effective solutions for correction.
- Ability to lead and maintain effective working relationships with all levels of employees, medical staff and external vendors.
- Advanced communication and interpersonal skills with all levels of internal and external customers.
- Ability to work independently, make decisions and take appropriate action when concerns arise. Self-motivated. Ability to work with sensitive and/or confidential information. Ability to prioritize multiple projects and manage time effectively.
Essentail Functions and Responsibilities:
- Provides oversight of compliance with various codes, laws, rules and regulations, including standards of the Healthcare Facilities Accreditation Program (HFAP) and other regulatory agencies, with respect to the general operations of doing business, as well as, those specific to healthcare and general patient care.
- Coordinates the development and implementation of multifaceted educational and training programs that focus on the elements of the compliance program, and ensures that all appropriate employees, management, and physicians are knowledgeable of, and comply with pertinent federal and state standards.
- Actively participates in the survey process and the preparation of corrective action plans as required by accrediting/regulatory agencies.
- Schedules and performs focused, mock and unannounced surveys to assess the organizations state of readiness for accreditation surveys and regulatory inspections.
- Assess survey results to identify potential risk. Develops and implements initiatives that improve the overall preparedness of the organization.
- Participates in policy development for both compliance and accreditation related issues and promotes quality and safety goals.
- Performs other duties as assigned.