Compliance & Accreditation Coordinator (RN-Registered Nurse) - Legal Services * Days - 40hrs/wk.
FTE status: 1
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 in all aspects of compliance and accreditation activities including but not limited to: the assessment and identification of compliance risk; the development and implementation of educational programs addressing compliance, Code of Conduct, and accreditation standards for staff and physicians; communicating the importance of reporting compliance concerns and the importance of the written Code of Conduct: and identifying and conducting evaluations relative to compliance standards. The Compliance and Accreditation Coordinator is required to maintain current on 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.
- 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.
- 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 focus, mock and unannounced surveys to assess the organizations state of readiness for accreditation surveys and regulatory inspections.
- Assess mock survey results in order to identify potential risk. Develops and implements initiatives that improve the overall preparedness of the organization and reduce the potential exposure to risk.
- Participates in policy development for both compliance and accreditation related issues and promotes quality and safety goals.
- Performs other duties as assigned. These may including but are not limited to: Maintaining a current knowledge base of use standards of care in professional practice, pursuing self-directed learning and continuing education opportunities, and participating on committees, task forces, and work groups as determined by management