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Job ID: 19459
Location: Raleigh, NC
Facility/Division: UNC REX Healthcare
Status: Full Time
Shift: Day Job
Become part of an inclusive organization with over 40,000 diverse employees, whose mission is to improve the health and well-being of the unique communities we serve.
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.
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.
● Bachelor's degree in Nursing required. Master's Degree in Nursing (or related field) highly preferred.
● 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.
Legal Employer: NCHEALTH
Entity: UNC REX Healthcare
Organization Unit: Rex Quality Programs
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Schedule: Day Job
Location of Job: US:NC:Raleigh
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.