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Accreditation and Licensure Manager

Wellstar North Fulton Hospital • Roswell, GA • Leadership • 106107 • Days • Full-Time


Under the leadership of the Director of Quality and Safety, the Manager of Accreditation and Licensure is an expert on The Joint Commission (TJC), CMS and other pertinent accreditation standards and must be able to independently lead all accreditation and licensure efforts. The Manager of Accreditation and Licensure is also responsible for continuous survey readiness including establishing mechanisms for proactive identification and correction of regulatory issues for hospital, outpatient departments, home care, and hospice (as applicable). In addition, this role develops and delivers educational training and coaching to facilitate the understanding of accreditation standards and requirements.


Core Responsibilites and Essential Functions

  • Continuous Readiness Program.
    * a. Coordinates and facilitates survey activity including, but not limited to Joint Commission Accreditation, CMS and State regulatory surveys. Provides consultative support for disease specific certification surveys.
    * b. Coordinates and oversees the use of tracer and mock surveys through utilizing electronic database to provide leadership trends of the findings.
    * c. Assures tracers and mock surveys are conducted as required with timely reporting and support to hospital departments and managers. Participates in system-wide mock survey activities.
    * d. Provide reports resulting from mock surveys and tracers by standards and elements of performance.
    * e. Routinely reviews regulatory and accreditation standards. Supports function area leaders, medical staff and others to ensure compliance by providing education and assisting with proactive identification of non-compliant practices.
    * f. Identifies high risk areas for regulatory compliance and facilitates education and process improvement efforts to create alignment and compliance.
    * g. Accountable for ensuring that action plans are developed to address deficiencies identified by regulatory agencies are fully executed by required deadliness and that actions are monitored for effectiveness and sustained improvement.
    * h. Communicates survey readiness success and potential barriers with Administrative, Hospital, and Physician Leaders.
    * i. Review accreditation applications annually and as needed.
  • Compliance with regulatory and accrediting agencies.
    * a. Monitors pertinent state and federal regulations, standards, and guideline.
    * b. Ensures changes in TJC and CMS standards and National Patient Safety Goals including monitoring
    * c. requirements are communicated with the appropriate department manager on a timely basis.
    * d. Responsible for Continuous Readiness for Regulatory Surveys and interpretation.
    * e. Maintains compliance with TJC, OSHA, CMS, NCCHC and all other appropriate standards or agencies.
    * f. Serves as a task force leader for project implementation for key initiatives and programs.
    * g. Monitors and analyzes current activities to determine business development value.
  • Education and Program Leadership
    * a. Develops, plan and implement key accreditation initiatives as defined by the organization.
    * b. Adheres to the general facility and system standards to promote a cooperative work environment by utilizing communication skills, interpersonal relationships, and team building.
    * c. Manages and provides guidance for Continuous Survey Readiness
  • Committee Oversight Participation
    * a. Collects, analyzes, recommends, and presents accreditation data and analysis of trends to hospital committees as appropriate.
    * b. Provides input into the design of an effective Accreditation plan through participation with hospital leadership and as an active part of the System Accreditation Committee. Serves as a liaison, ensuring coordination and consistency between the facility plan and WellStar Health System?s Program for Continuous Survey Readiness. Reviews and analyzes annually.
  • Data Collection and Analysis
    * a. Uses available Accreditation Management software to collect data to provide reports for the hospital
    * b. and outpatient department.
    * c. Provides support for data collection and analysis, including the ongoing systematic screening of data sources and special studies to evaluate survey readiness.
    * d. Correlates data from various mock survey, tracer and official survey activities to include problem identification, investigation and resolution, as well as monitoring and trending patterns.

Required for All Jobs

  • Performs other duties as assigned
  • Complies with all WellStar Health System policies, standards of work, and code of conduct.


Required Minimum Education

  • Bachelor's Degree (Nursing or healthcare-related field required) Required and
  • MBA Preferred or
  • Master's Degree in healthcare-related field Preferred

Required Minimum Experience

  • Minimum 2 years in healthcare, nursing or clinical practice Required and
  • Minimum 2 years of experience with hospital accreditation and licensure programs (e.g. The Joint Commission, CMS) Required

Required Minimum Skills

  • Proven ability to analyze, interpret, and display data; 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.

Required Minimum License(s) and Certification(s)

  • Cert Joint Commission Prof Preferred

Additional Licenses and Certifications

  • CJCP certification required within 24 months from date of hire. Required
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