5-7 years of experience in quality management or accreditation roles
Strong knowledge of CMS, DNV, and state regulations
Proficient in data analytics and database management
Excellent communication and interpersonal skills
Ability to work independently and manage multiple tasks
Experience in conducting chart audits and tracer methodologies
Responsibilities
Independently gather and summarize information for reporting purposes
Educate self on standards and regulations from various accrediting bodies
Perform chart audits on current inpatients and conduct tracers
Coordinate logistics for survey preparation and corrective actions
Lead Accreditation presentations and departmental meetings
Identify opportunities for improvement within the organization
Assist with oversight of department intranet content
Benefits
Opportunities for continued education and professional development
Supportive work environment with access to leadership
Engagement in meaningful work that promotes patient safety
Collaboration with various stakeholders to enhance quality measures
Access to resources for maintaining compliance with accreditation standards
Full Job Description
Department/Unit: Quality Management
Work Shift: Day (United States of America)
Salary Range: $94,957.00 - $147,183.00
The Accreditation Specialist is responsible for chart review/abstraction and closed record review as well as audit activity to promote patient safety and continuous compliance with accrediting organizations and CMS. This role will be responsible for assisting the department or division head in overall administration of work unit/department and requires a demonstrated high degree of knowledge, competence, and administrative support skills, and the ability to operate with considerable independence.
JOB FUNCTIONS
Independently gathers and summarizes information for reporting and other purposes.
Pursues continued education of standards, regulations, and requirements as put forth by the DNV, CMS, New York State, DOH, OSHA, and other regulatory bodies.
Educates self and has the ability to use the audit system proficiently.
Works with departmental leadership and other applicable stakeholders to resolve questions and issues.
Independently gathers and summarizes information for reporting and other purposes.
Meets all accreditation and CMS regulations for chart review.
Ability to use data analytics and databases to enter raw data, organize data, run reports, and help make interpretation of the data.
Uses proper protocols to access, view, and distribute personal health information necessary to do the job.
Performs chart audits on current inpatients and can perform tracers in patient care areas.
Coordinates and supports logistics during survey preparation, survey activity, and deficiency corrective action.
Copies, faxes and scans as needed to communicate for the department.
Establishes, maintains, and revises record keeping systems.
Meets all accreditation/CMS regulations for chart review protocols and assist department to do the same.
Greets, identifies and directs internal/external staff/inquiries in person or by telephone, and follows up as needed. Provides information and identifies solutions to address issues that arise and refers to appropriate person/authority as needed.
Available to all personnel who ask questions/make requests in a timely manner.
Assists users to obtain access to and training for the audit system.
Works with various programmatic groups to develop and implement strategies to improve Leapfrog measures.
Leads Accreditation presentations and other Accreditation Department led meetings, as necessary.
Proactively identifies and examines opportunities for improvement within the organization.
Leads departmental Environment of Care Rounds through appropriate patient care areas including hospital and clinical settings.
Escalates barriers identified if unable to help mitigate via chain of command within the department in a timely manner.
Assists with the oversight of the department intranet website content.
Additional duties as assigned.
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