This job directs, plans, and coordinates the accreditation process within the organization. Provides leadership in maintaining compliance to accreditation and regulatory standards. Collaborates with department leadership to educate and interpret accreditation standards. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties. This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities. Contents are subject to change at the company's discretion. Education Required - High school diploma or equivalent. Preferred - Bachelor's degree. Work Experience Required - 10 years of healthcare related experience or five years of experience working as a professional in a healthcare environment with a bachelor's degree. Experience managing complex processes with general knowledge of the principles and theories of quality management, continuous quality improvement and regulatory and accrediting standards. Experience working with highly confidential information. Knowledge Skills and Abilities (KSAs) 3 Proficiency in using computers, software, and web-based applications. 3 Effective verbal and written communication skills and ability to present, information clearly and professionally to varying levels of individuals throughout the patient care process. 3 Excellent organizational skills. 3 Ability to travel throughout and between facilities and work a flexible work schedule (e.g. 24/7, weekend, holiday, on call availability). Job Duties 3 Provides consultation, education and interpretation to the organization related to accreditation and regulatory standards and provides education to the organization related to patient safety and performance improvement. 3 Coordinates and conducts regularly scheduled Joint Commission tracers and facilitates organizational continued Joint Commission (TJC) readiness. 3 Provides consultation, education and interpretation to the organization related to unanticipated complaint follow up visits. 3 Assists leader in other departmental initiatives as assigned such as clinical quality data collection and analysis, accreditation, and survey preparation. 3 Facilitates implementation teams related to accreditation and regulatory standards. 3 Maintains assigned service line facilitation of quality initiatives. 3 Performs other related duties as required. The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills. Other duties may be added, or this description amended at any time. Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards. Physical and Environmental Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Sedentary Work - Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. Normal routine involves no exposure to blood, body fluid or tissue and as part of their employment, incumbents are not called upon to perform or assist in emergency care or first aid. There is no occupational risk for exposure to communicable diseases Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and/or disposal of contaminated waste. The risk level of exposure may increase depending on the essential job duties of the role.