Accreditation Specialist

Oversees all ongoing activities and policies related to regulatory compliance. Serves as a resource/ liaison to provide interpretation, expertise and advice regarding maintenance of standards required by the Accreditation Commission for Healthcare (ACHC) and other regulatory agencies to administration, medical staff, department directors and Kearney Regional Medical Center (KRMC) staff. Provides data to support a culture of excellence and change. Evaluates hospital-wide clinical and patient-related processes, analyzes these processes for clinical effectiveness, patient safety, and efficiency, and makes recommendations for improvements and redesigns that enhance the quality and safety of patient care in the organization. Reviews the quality of contracted services and incorporates into the hospital wide QAPI program. 1.

• Commits to the KRMC mission, vision, values and goals and consistently demonstrates our core values. 2.
• Serves as primary liaison with regulatory and accreditation bodies such as

ACHC & CMS. 3.

• Coordinates program-specific certification preparations with directors and staff responsible. 4.
• Meets or exceeds ACHC and other regulatory and accreditation standards.

5. Works collaboratively with organizational and external stakeholders to complete licensure applications and maintain accuracy of licenses for KRMC. 6. Completes annual organizational and system AHA surveys with support and validation of leaders in the organization. 7. Provides leadership and participates in improvement initiatives and teams assigned. 8.

• Provides oversight of the required clinical data retrieval, analysis and submission to external agencies to support quality improvement initiatives and compliance with regulations and standards. 9.
• Maintains current knowledge of regulatory and accrediting agencies requirements and ensures that requirements are addressed on an ongoing basis. 10.
• Provides direction as needed to ensure policy and procedures systems are administered according to organization standards. 11.
• Serves as liaison with all departments for the monitoring, review and analysis of identified clinical quality and process improvement projects.

12. Maintains current knowledge of applicable federal and state accreditation standards, and monitors advancements to ensure organizational adaptation and compliance. Communicates regulatory and accreditation changes as appropriate. 13. Implements the Medical Center Corporate Compliance Plan; assists with review of the Medical Center's plan for Patient Care Services and recommends adjustments. 14. Assists in the development and implementation of the facility quality and safety plan. 15.

• Organizes and serves as the facility host for regulatory and accreditation guests. Develops follow up plans and responses for all regulatory and accreditation findings. 16.
• Serves as internal consultant to senior management, medical staff and hospital departments in all matters related to regulatory agency standards and compliance.

17. Reports progress, results or barriers preventing successful implementation of projects to Director. 18. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise. 19. Participates in meetings, committees and department projects as assigned. 20. Performs other related projects and duties as assigned.

EDUCATION AND EXPERIENCE

Associate's degree in Nursing, Healthcare Administration, or related healthcare field required. Bachelor's degree in Nursing, Healthcare Administration, or related field preferred. Minimum of five (5) years of experience in healthcare operations, quality, regulatory compliance, accreditation, or related area required. Experience developing, implementing, or supporting improvement or compliance programs preferred.