Facility: Spalding Medical Center

Job Summary:

Under the leadership of the Director of Quality and Safety OR Accreditation and Licensure Manager, the Coordinator of Accreditation and Licensure serves as an expert to promote compliance of licensure, certification and accreditation standards among WellStar facility team members, leaders, and physicians. Responsibilities include but are not limited to: the development and facilitation of a cohesive survey readiness team. In addition, the role delivers education at all levels and assesses survey readiness through mock surveys and patient tracers including collaborating with hospital and system leaders to establish and monitor action plans for improvement.

Core Responsibilities and Essential Functions:

Program Coordination a. Maintains the Joint Commission extranet site including, but not limited to, the hospital application with each HOD or new hospital program addition, required document submission and official TJC communications. b. Collaborates with and supports hospital specific certification programs with all functions of survey preparation, implementation, and post survey requirements. c. Educates new or amended requirements based on audience level of need. d. Provides expertise in the development of action plans to resolve gaps. e. Develops audit and tracer tools to ensure clear and specific guidelines for inter-rater reliability. f. Analyzes data to produce information and knowledge. g. Utilizes accreditation software for auditing tracking compliance to standards. h. Coordinate local accreditation non-compliance standards to the system level Accreditation Committee. i. Review accreditation applications annually and as needed. Survey Coordination a. Maintains and updates the required survey documents for unannounced surveys. b. Reviews, edits, and executes the hospital’s Survey Implementation Plan. c. Serves as the hospital’s representative for all surveys. d. Communicates survey progress and potential problems with the Quality and Patient Safety leader. e. Responsible for all post survey requirements including the timely submission of corrective action plans. Policy and Procedures a. Consults on policies at the hospital and system levels. b. Supports patient safety activities by conducting policy and procedure reviews to support Root Cause Analysis. c. Communicates new or revised policy and procedures to the members of the hospital teams.

Required Minimum Education:

Bachelor's Degree (Nursing or healthcare-related field preferred). Required

Required Minimum License(s) and Certification(s):

Cert Joint Commission Prof 1.00 Preferred

Additional Licenses and Certifications:

Required Minimum Experience:

Minimum 2 years of experience in a healthcare setting. Required Minimum 1 year with hospital accreditation and licensure programs (e.g. The Joint Commission, CMS) Preferred

Required Minimum Skills:

Strong attention to detail; meticulous accuracy and thoroughness Superior organizational and interpersonal skills with ability to work independently as well as with a team Demonstrated excellence in interpersonal and written communication skills required High degree of professionalism, discretion, and confidentiality Strong computer skills, including but not limited to Microsoft Office and accreditation software Proficiency in problem solving and negotiating teams to reach consensus Ability to build relationships and foster communication among stakeholders in clinical and non-clinical settings