Accreditation Coordinator

Job Description

Description

Become part of an inclusive organization with over 40,000 teammates, whose mission is to improve the health and well-being of the unique communities we serve.

The Accreditation Coordinator ensures compliance with healthcare standards by conducting patient safety rounds, assisting with regulatory surveys, maintaining survey readiness, and educating staff on accreditation and regulatory requirements. This full-time position typically follows a standard work schedule, Monday through Friday, within a dynamic and collaborative healthcare environment.

The preferred candidate is a nurse with previous experience in healthcare accreditation and regulatory compliance or in healthcare leadership/educator. This candidate will have strong organizational and communication skills, excellent educational abilities and works effectively in a team-oriented setting. 

Summary: Prepare the Rex Healthcare system leaders/co-workers for surveys and the accreditation process through mock surveys, focused tracers, articles, computerized learning modules, newsletters, presentations, accreditation website, and consultations with clinicians and departments.

Responsibilities:
1. Facilitate the interpretation of the Joint Commission Standards and Center for Medicare and Medicaid regulations (hereto referred to as standards and regulations) with/for organization's leadership team.

2. Ensure organizational readiness and the ongoing compliance with the standards and regulations across the Rex Healthcare system.

3. Report the status of hospital-wide standards compliance to organizational leaders.

4. Prepare the Rex Healthcare system leaders/co-workers for surveys and the accreditation process through mock surveys, focused tracers, articles, computerized learning modules, newsletters, presentations, accreditation website, and consultations with clinicians and departments.

5. Develop and provide education to Rex co-workers.

6. Coordinate investigations and reply to patient/family complaints sent to Rex Healthcare by Joint Commission.

7. Manage TJC/CMS/Division of Health Services Regulation (DHSR) surveys effectively. Prepare and coordinate written responses to TJC, CMS, or DHSR surveys, as needed.

8. Participate in the Patient Safety Team and root cause analysis of sentinel events. Create/assist with action planning to prevent these events in the future.

9. Maintain extensive knowledge of the most current accreditation, certification, and licensure requirements and standards, independent judgement, decision making, data collection, validation and analysis techniques, Quality Improvement concepts and tools, risk management, operational policies and patient safety and care standards.

Other Information

Other information:
Education Requirements:
● Bachelor's degree in Nursing required. Master's Degree in Nursing (or related field) highly preferred.
Licensure/Certification Requirements:
● RN NC LIC
Professional Experience Requirements:
● Four years of experience in administration or patient care in a hospital setting. Experience in Joint commission accreditation process and experience in outcomes and performance management is highly preferred.
Knowledge/Skills/and Abilities Requirements:
● Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community. Ability to write speeches and articles for publication that conform to prescribed style and format. Ability to effectively present information to top management, public groups, and/or boards of directors. Ability to apply advanced mathematical concepts such as exponents, logarithms, quadratic equations, and permutations. Ability to apply mathematical operations to such tasks as frequency distribution, determination of test reliability and validity, analysis of variance, correlation techniques, sampling theory, and factor analysis. Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions.

Job Details

Legal Employer: NCHEALTH

Entity: UNC REX Healthcare

Organization Unit: Accreditation

Work Type: Full Time

Standard Hours Per Week: 40.00

Salary Range: $33.04 - $47.50 per hour (Hiring Range)

Pay offers are determined by experience and internal equity

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: US:NC:Raleigh

Exempt From Overtime: Exempt: Yes

This position is employed by NC Health (Rex Healthcare, Inc., d/b/a NC Health), a private, fully-owned subsidiary of UNC Heath Care System. This is not a State employed position.

Qualified applicants will be considered without regard to their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

UNC Health makes reasonable accommodations for applicants' and employees' religious practices and beliefs, as well as applicants and employees with disabilities. All interested applicants are invited to apply for career opportunities. Please email [email protected] if you need a reasonable accommodation to search and/or to apply for a career opportunity.