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Job ID: 2199
Location: Chapel Hill, NC
Facility/Division: UNC Medical Center
Status: Full Time
Shift: Day Job
Become part of an inclusive organization with over 30,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.
This position is responsible for accreditation and regulatory compliance preparation activities for UNC Medical Center in Chapel Hill. The Accreditation Manager coordinates multi-disciplinary team participation in Joint Commission, state and federal surveys. The position also provides technical assistance to stakeholders on matters pertaining to the application of Joint Commission standards, CMS regulations and North Carolina Division of Health Service Regulation requirements.
1. Accreditation Knowledge- Maintains extensive knowledge of the most current accreditation standards and related state and federal regulations.
2. Investigations- Coordinates investigations and responses to complaints received from The Joint Commission. Participates in root cause analysis review of sentinel events. Assists with development and monitoring of corrective action plans.
3. Regulatory Standards- Provides guidance on the interpretation and application of Joint Commission standards, state and federal regulations for the organization's stakeholders. Prepares policies and educational materials required for accreditation and regulatory compliance.
4. Survey Management - Effectively manages Joint commission, CMS and Division of Health Services Regulation (DHSR) surveys. Prepares and coordinates written responses and follow-up.
5. Survey Readiness and Ongoing Compliance- Ensures organizational readiness and ongoing compliance with standards and regulations across UNC Medical Center. Leads activities designed to monitor and improve compliance with standards, including focused tracers, mock surveys and educational sessions.
● Bachelor's degree in Nursing (BSN) or related field.
● No licensure or certification required.
Professional Experience Requirements:
● Four (4) years of experience in administration or patient care in a hospital setting.
Knowledge/Skills/and Abilities Requirements:
● Position requires strong written and verbal communication skills. Experience with Microsoft Office and electronic medical record systems desired.
Entity: UNC Medical Center
Organization Unit: Risk Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Schedule: Day Job
Location of Job: US:NC:Chapel Hill
Exempt From Overtime: Exempt: Yes
The UNC Health System and the UNC School of Medicine are committed to valuing all people throughout our organization, regardless of background, lifestyle, and culture. A diverse and inclusive work environment for staff and culturally appropriate care for our patients, are essential to fulfilling our UNC Health vision of improving the health of all North Carolinians.
UNC Health is an equal opportunity employer. As such, UNC Health offers equal employment opportunities to applicants and employees without regard to race, color, religion, sex, national origin, age, genetic information, disability, sexual orientation, gender identity or political affiliation.