ACCREDITATION COORD., ACCREDITATION SVCS, FT DAYS

Comapny: Mission Hospitals Reference Code: 10053 Asheville is consistently ranked among the best places to live in the country. The area is alive with the arts, theater, music, street festivals, fine dining, shopping and an abundance of outdoor activities. Mission Hospitals is a nationally recognized, 700+ bed hospital and designated Level II Trauma Center. Our commitment to diversity and inclusiveness is vital - in sustaining our diverse workforce and in meeting the needs of our diverse patient population. We work hard to promote an environment that brings out the best in our staff, making sure our employees have the opportunities, resources and support they need to continue growing and making a difference as professionals. As an equal opportunity employer, we strive to make Mission a welcoming and responsive place for all who work here and all who seek our care. ACCREDITATION COORD., ACCREDITATION SVCS, FT DAYS Requirements Provides comprehensive assessment, planning, monitoring and evaluation for compliance with accreditation and regulatory agency standards.Essential Accountabilities:1. Maintains personal expertise and database of current initiatives being taken by accrediting agencies.Performance Criteria: 1. Timely review of regulatory guidelines, journals, newsletters. 2. Maintains relationship with agent representatives. 3. Attendance at educational programs.2. Obtains and disseminates standards, regulations, etc. to those in the organization who need to know.Performance Criteria: 1. Disseminates definitive interpretations of standards with respect to organization's functions. 2. Chairs and directs the Joint Commission Leadership Team. 3. Participates and acts as facilitator on Joint Commission Leadership Teams. 4. Oversees the dissemination of JCAHO, CMS, DFS and other regulatory body information and updates. 5. Plans for the JCAHO monthly video conferences.3. Ensures continuous compliance with all relevant standards at all times.Performance Criteria: 1. Assesses, monitors and recommends, as appropriate, activities and educational opportunities to maintain compliance with accreditation and/or regulatory standards. 2. Works with staff from all relevant areas to communicate, plan for, monitor and evaluate new developments in regulation, standards, or legislation.4. Identifies, plans for and assists in implementation of changes required by new/evolving standards by teaching and monitoring.Performance Criteria: 1. Serves as a resource for staff by assisting leadership in identifying and facilitating changes to support compliance. 2. Provides formal and informal teaching on an ongoing basis. 3. Periodically reports to the leadership team announced or potential changes in regulations and/or standards; related implementation plans to assure compliance; monitoring and evaluation of compliance with all current standards/regulations; progress on implementation of policies, procedures, and activities needed to assure continuing compliance. 4. Develops consultation and mock surveys to support departments in achieving and exceeding continual compliance.5. Devise, implement and direct continuous survey readiness.Performance Criteria: 1. Complete 18-month organizational self-assessment and report to JCAHO.6. Coordinates the survey function. Coordinates site visits, follow-up reports, activities and historical files.Performance Criteria: 1. Provides documentation and other information as requested by regulatory and accrediting bodies. 2. Regularly reports to the leadership team planned visits by external agencies and results of visits. 3. Coordinates all announced and unannounced survey activities.Required Education: Bachelor's DegreePreferred Education: Master's DegreeRequired License: Registered Nurse in the State of North Carolina or compact state if applicablePreferred License: NoneRequired Experience: Knowledge of Joint Commission standards with a minimum of 5 to 7 years experience in a clinical or administrative management role.Preferred Experience: Specific experience in dealing with accreditation and regulatory agencies.* Apply to this job